
Class JRJ>_LC I. 
Copyright N" 

COPVRIOIIT DEPOSIT. 



I 



PRACTICAL GYNECOLOGY 



MONTGOMERY 



Practical Gynecology 



A COMPREHENSIVE TEXT- BOOK 
FOR STUDENTS AND PHYSICIANS 



BY 



E. E. MONTGOMERY, M.D., LL.D. 

PROFESSOR OF GYNECOLOGY, JEFFERSON MEDICAL COLLEGE ; GYNECOLOGIST TO THE JEFFERSON MEDICAL 

COLLEGE AND ST. JOSEPH'S HOSPITALS ; CONSULTING GYNECOLOGIST TO THE PHILADELPHIA 

LY'ING-IN CHARITY- AND THE KENSINGTON HOSPITAL FOR WOMEN 



XTbtrb IReviset) lEMtton 



WITH FIVE HUNDRED AND SEVENTY-FOUR ILLUSTRATIONS, THE GREATER 
NUMBER OF WHICH HAVE BEEN DRAWN AND ENGRAVED SPECIALLY 
FOR THIS WORK, FOR THE MOST PART FROM ORIGINAL SOURCES 



PHILADELPHIA 

P. BLAKISTON'S SON & CO. 

I0I2 WALNUT STREET 
1907 



-^^ 



\0 



LIBRARY of congress] 

Two Cooles Received 

APh 23 \901 

^ «opyiriKht Entry , 



CUSS 



5S A XXc, 



No. 
COPY B. 



Copyright, 1907, by P. Btakiston's Son & Co. 



WM. F. FELL, cor 

EUECT ROT YPE RS, P 

PHll-ADEUPHIA, 



TO 

Dr. m. lb. Marker, 

A\Y CONSCIENTIOUS INSTRUCTOR AS QUIZ = MASTER AND HOSPITAL CHIEF, 
AND MY GENEROUS FRIEND, 

THIS BOOK IS RESPECTFULLY DEDICATED. 



PREFACE TO THE THIRD EDITION. 



This book has been carefully revised for the third edition, and 
some seventy pages of new material have been added. Micro- 
scopic diagnosis, gynecic bacteriology, and the pathology of 
carcinoma uteri have been rewritten. 

The subjects of Etiology and Blood Examination have been 
added. 

Of the new illustrations Nos. 42, 295, 471, 472, 473, 474, 480, 
481, 482, 484, 486, 488, 492, 511, 512, 519, 520, 532, S33^ and 
556 were prepared by Miss S. L. Clark, and Xos. 78, 79, 415, 
416, and 417 by Miss E. A. Cantner. 

I desire to express my indebtedness to Dr. P. B. Bland for 
having written the blood examination and microscopic diagnosis, 
and for valuable suggestions in the pathology of cancer; and 
to Miss E. A. Cantner for preparation of the index. 

Philadelphia, March 2j, iQOj. 



PREFACE TO THE SECOND EDITION. 



In presenting a second edition of this work, I desire to express 
my sincere gratification over the generous and flattering recep- 
tion the first edition has obtained from the medical press and 
the profession. 

]^Iany changes have been made in the arrangement of the 
different divisions which experience has led me to believe will 
prove of benefit to the student. ^Malformations are confined 
to congenital conditions, while the lesions of parturition are 
treated under the designation of Traumatisms. Disorders of 
the Fallopian tube and the ovary are more specifically treated 
in Inflammation. The specific treatment of the various de- 
viations is discussed in close relation with each subject. The 
division comprising genital tumors has been extensively changed 
in the consideration of myomata and malignant growths. 

It has been my purpose in the entire revision to increase the 
usefulness of the work to the student by treating, in closer detail, 
the later operative procedures, and in order to accomplish this the 
greater part of the work has been rewritten, which has added 
some seventy pages. The illustrations have been increased in 
number and many of them redrawn. Xew illustrations made 
from material secured from my own practice have been largely 
substituted for the microscopic drawings of the former edition. 

I here take occasion to express my thanks to Mr. H.J. Shan- 
non for the care and painstaking skill with which he has cor- 
rected many of the old drawings and constructed several new 
ones, notably those illustrating the Doyen operation for uterine 
myomata; to ]\Iiss S. L. Clark for drawings of microscopic sec- 
tions from which the following illustrations were prepared, figures 
48 and 49 a and b, 126, 130, 132, 133, 296, 299, 300, 302, 306, 307, 
5io» 513* 53I' 534, 535, 549; to Miss Karin M. Hall for drawings 
for figures 301, 310, 311; to Professor W. M. L. Coplin, M.D., 



X PREFACE TO THE SECOND EDITION. 

for his kind supervision of the preparation of the microscopic 
drawings and for many valuable suggestions; to Drs. J. M. 
Fisher, John C. DaCosta, Wilmer Krusen, and C. P. Noble for 
the loan of specimens from which illustrations were prepared. 

I am indebted to Dr. P. Brooke Bland for the preparation of 
the slides from which the microscopic illustrations were made, for 
correction of the manuscript, and for assistance with the index ; to 
Miss E. A. Cantner for the rearrangement and preparation of the 
index and table of contents. The publishers deserve m}^ un- 
stinted praise for their generous expenditure for redrawing the 
old and in the preparation of new illustrations, and for their 
purpose to present the work in an attractive form. 

It is my sincere hope that this edition shall render the phy- 
sician more efficient in lessening the ills of women and adding 
comfort and pleasure to their lives. 

Philadelphia, September 15, 1903. 



PREFACE TO FIRST EDITION 



I will offer no apology for presenting an additional text -book 
upon gynecology. 

This work has been under consideration for the last fifteen 
years, and much of it has been several times rewritten. An 
effort has been made to make it a comprehensive work upon the 
subject, giving the experience and methods of the most careful 
men, while my own experience has been utilized to indicate that 
which I have found most useful and worthy of acceptance. 

Each general subject is considered with reference to its influ- 
ence upon the entire genital tract, and the work is divided into 
sections rather than chapters. This course, although a departure 
from the ordinary text-book arrangement, is that which expe- 
rience has demonstrated to be most effective in impressing the 
subject upon the student, and would seem to me preferable to 
him who uses the book to refresh his knowledge upon any par- 
ticular subject. The illustrations are arranged solely with the 
purpose of rendering clear the text and to promote the work of 
diagnosis and treatment. For their excellence and character I 
am greatly indebted to the generosity of the publishers and to 
the skill and patience of their artists, Messrs. Shannon and Von du 
Lancken. To the kindly oversight of Dr. Robert L. Dickinson 
is due much of the exactness of the drawings. Acknowledgment 
is due Miss Eleanor A. Cantner for her ability in the preparation 
of preliminary sketches and of the index. 

Should it be the means of lightening the work of the student, 
of making more clear the pathway of the busy practitioner, and, 
most of all, of benefiting suffering women through improved 
methods of diagnosis and treatment, I shall feel well repaid for 
the many days and nights of labor which it has cost 

The Author. 

Philadelphia, August, igoo. 



TABLE OF CONTENTS. 



INTRODUCTION. 

SECTION. PA(;E. 

1 . Definition and Antiquity, i 

2. Theories, i 

3. Foundation, i 

4. Purpose, I 

ETIOLOGY. 

5. Importance of Etiology, 2 

6. Classification, 2 

7. (A) Hereditary and Congenital Causes, 3 

8. (B) Hygienic Causes, 5 

9. (C) Sexual Causes, 7 

10. (D) Traumatic Causes, 8 

11. (E) Infective Causes, 10 

12. (F) Causes Incident to Age, 11 

13. Difficulties in Study, 12 

14. Observation, 12 

15. Exercise of Judgment, 13 

16. Value of Notes, 13 

1 7 . History, 13 

DIAGNOSIS. 

18. Subjective Symptoms 14 

19. Causes of Error, 14 

20. Method of Procedure, 14 

2 1 . General Symptoms , 15 

22. Visceral Neuralgias, 15 

23. Neuralgia 15 

24. Motor and Sensory Paralysis, 15 

25. Disorders of Nutrition, 16 

26. Chlorosis 16 

27. Anemia, 16 

28. Local Symptoms, 16 

29. Rectal Reflexes 17 

30. Vesical Reflexes 18 

3 1 . Genital Symptoms, 18 

3 2 . Hemorrhage, 18 

33. Pain, 19 

34. Seats of Pain 19 

3 5 . The Iliac Pain, 19 

36. Lumbar Pain, 20 

37. Hypogastric Pain, 20 

38. The Accessory Seats of Pain 20 

39. The Anal or Perineal Pain, 20 

40. Vaginal Pain, 20 

41. Pelvic Pain, 20 

42. Leukorrhea 20 

43. The Secretion from the Fallopian Tubes and Cavity of the Uterus, . . 20 

44. The Secretion of the Vagina and Vulva, .' 20 

xiii 



XIV TABLE OF CONTENTS. 

SECTION. PAGE 

45 



Catarrhal Discharge, 21 

Origin of Discharge, 21 

Discharge Simulating Abscess, 21 

Other Sources for Purulent Discharges, 21 

Cervical Discharge, 22 

Vaginal Discharge, 22 

Effect of Age upon the Discharge, 22 

Physical Signs, 22 

Senses Employed, 22 

Examination, 23 

Pelvic Examination, 23 

Abdominal Examination, 23 

Preliminaries, 23 

Positions, 23 

The Dorsal Position, 23 

The Lateral Position, ' 24 

The Semiprone or Sims' Position, 24 

The Genupectoral Position, 25 

The Trendelenburg Position, 26 

The Erect Position, 27 



PELVIC EXAMINATION. 

65 . Inspection, 27 

66. Simple Touch, 27 

67 . Preparation, 27 

68. Procedure, 27 

69. Bimanual Procedure, 30 

70. Difficulties, , 30 

7 1 . Virgins, 30 

72. Rectal Touch, 31 

73. Simon's Method, S3 

74. Vaginal Section, ;^s 

75. Precautions, 34 

76. Instrumental Examination, 34 

7 7 . Probes, ._ 35 

78. Piccautions .■ . . 37 

79. Speculum 37 

80. The Tubular Speculum, 37 

8 1 . Valvular Speculum 38 

82. The Univalve or Duck-bill Speculum, 41 

83. Uterine Fixation and D( wnward Traction, 43 

84. Dilatation of the Uterus 43 

85. Dilatation by Tents, 44 

86. Divulsion, 45 

87. Gradual Dilatation 46 

88. Incision of the Cervix, 46 

89. Complete Bilateral Incision of the Cervix, 47 

90. Dilatation by Gauze Packing, 48 

91. Microscopic Examination, 48 

92. Collection of Tissue, 49 

93. Test Excision, 49 

94. Test Curetment 5° 

95. Disposition of Tissue, 52 

96. Examination, 52 

97. Preservation of Gross Specimens and Slides, 5^ 

98. Failure, 60 

99. Bacteriology of the Genital Tract, 60 

100. Parasites of the Genital Tract 61 

10 1. Natural Agents of Immunity, 62 

102. Loss of Protection, 62 

103. Parasites, 63 



TABLE OF CONTENTS. XV 



Staphylococcus, 63 

Streptococcus, 64 

The Gonococcus, 65 

Bacillus Coli Communis, 68 

Bacillus Tuberculosis, 68 

Syphilis and Chancroid 70 

Bacillus Typhosus 71 

Smegma Bacillus. 72 

Bacillus Pyocyaneus 72 

Bacillus Aerogenes Capsulatus, 72 

Diphtheria Bacillus 72 

Pneumococcus 73 

Diplococcus of Siegelman, 73 

ANIMAL PARASITES. 

117. Pediculosis Pubis or Inguinalis, 73 

1 18. Acarus Scabiei ■. 73 

I ig. Oxyuris Vermicularis, 73 

1 20. Ascaris Lumbricoides, 74 

121. Tenia Echinococcus 74 

122. Collection of Fluids and Secretions 75 

123. Blood Changes, 76 

124. Examination of the Blood, 76 

125. The Specimen 76 

126. Method of Collection 77 

127. Microscopic Examination of Fresh Specimen, 77 

128. Fixation for Staining 78 

129. Staining, 78 

130. Counting the Corpuscles, 8a 

131. Estimation of Hemoglobin, 81 

132. Composition of the Blood, 82 

133. Erythrocytes 8^ 

134. Color Index, 83 

135. Relation of Hemoglobin to Surgery, 84 

136. Normal Number of Red Cells, 84 

137. Increase in the Number of Erythrocytes, 85 

138. Pathologic Alteration of the Erythrocytes 85 

139. Platelets 85 

140. Hemoconia, 85 

141. Leukocytes 86 

142. Leukocytosis, 87 

143. Leukocytosis of Digestion 87 

144. Leukocytosis of Pregnancy and Parturition, 87 

145. Thermal and Mechanical Agencies, 87 

146. Terminal Leukocytosis 87 

147. Pathologic Leukocytoses, 88 

148. Post-hemorrhagic Leukocytosis, 88 

149. Leukocytosis (Phagocytosis) 88 

150. Inflammatory Leukocytosis, 88 

151. Malignant Leukocytosis, 89 

152. Toxic Leukocvtosis 80 



153. Experimental Leukocytosis, 89 

154. Bacteremia 9a 

155. Bacteria Found in Blood 90 

156. Blood Culture, go 

157. Blood Coagulation, 91 

158. Exploration of the Urethra, Bladder, and Ureters, 91 

ABDOMINAL EXAMINATION. 

159. Preliminaries, 96 

160. Inspection, 97 



XVI TABLE OF CONTENTS. 

SECTION. PAGE, 

i6i. Palpation, 98 

162. Difficulties, 99 

163. Percussion, 99 

164. Auscultation, 99 

165. Exploratory Puncture, 100 

166. Tapping, or Paracentesis Abdominis, 100 

167. Aspiration, i o i 

168. Exploratory Incision, 102 

THERAPEUTICS. 

169. Classification 102 

170. Extension, 102 

171. Infection, 102 

172. Terms, 102 

173. Sterilization Methods, 103 

174. Sterilization of Instruments, . . .' 104 

175. Sponges, _ 105 

176. Ligature and Suture Material, 106 

177. Dressings, 108 

178. Operator and Assistants, 108 

179. Precautions 109 

180. Room and Environment, no 

181. Examination and Preparation of Patient, no 

182. Special Preparation, in 

183. Irrigating Tubes, 112 

184. Gauze, 113 

185. Antisepsis of the Cervix and Uterine Cavity, 113 

186. The Use of Tents, n4 

187. Abdominal Section, 114 

188. Indications for Anesthesia, 115 

189. Agents Employed, 115 

190. Administration, 117 

191. Local Anesthesia, 118 

192. Preliminary Details of Operation, 119 

193. Arrangement, 120 

194. Positions of Operator and Assistants, 120 

195. Clothing of Patient, 120 

196. Incision, 121 

197. Adhesions, 124 

198. Toilet of the Peritoneum, 125 

199. Drainage, 125 

200. Objections to Drainage, 126 

201. Gauze Drain, 128 

202. Where Placed, 128 

203. Postural Drainage, 128 

204. Closure of the Wound, 129 

205. Dressing, 131 

206. Postoperative Treatment 131 

207. Comfort of Patient, 132 

208. Vomiting, 133 

209. Tympanites, 134 

210. Shock, 135 

211. Anodynes 135 

212. Internal Hemorrhage, 135 

213. Peritonitis, 135 

214. Wound Infection, 136 

215. Parotiditis, 137 

216. Ileus 137 

217. Phlebitis, 138 

218. Precautions in the Use of the Hypodermic Syringe, 138 

219. Catheterization, 139 



TABLE OF CONTENTS. XVll 

SECTION. PAGE. 

2 20. Removal of Sutures, 139 

221. Getting Up,. . ._ , 140 

222. Plastic Operations 140 

MEDICAL TREATMENT. 

223. General Treatment, 140 

224. Specific Remedies, 141 

225. Rest and Exercise, 142 

LOCAL THERAPEUTICS. 

226. Baths 143 

227. Douche. 143 

228. External Applications, 144 

229. Counterirritants, 144 

230. Bloodletting, 144 

231. Local Applications, 145 

232. Various Agents, 145 

233. Astringents, ' 146 

234. Caustics 146 

235. Tampons, 146 

236. Massage 147 

237. Pelvic Massage, 147 

ELECTRICITY. 

238. Forms, 149 

239. Franklinism, 149 

240. Galvanism, 149 

241. Apparatus for Application, 150 

242. Method of Procedure, 151 

243. Indications, 152 

244. Contraindications, 152 

245. Faradic 152 

246. Sinusoidal, 153 

247. Rontgenic 154 

248. Finsen Light, 155 

249. Electrocautery and Light, 155 

EMBRYOLOGY AND ANATOMY OF THE GENITO-URINARY 
ORGANS OF THE WOMAN. 

250. Development of the Genito-urinary Organs, 156 

251. Division of the Genitalia, 159 

252. The External Genital Organs, 159 

253. The Mons Veneris, 159 

254. The Labia Majora, 159 

255. The Labia Minora, '. 160 

256. The Clitoris 161 

257. The Vestibule, 162 

258. The Hymen, 164 

259. The Fourchet, 165 

260. The Muscles of the Perineum, 165 

261. The Perineal Fascia, 168 

262. Pelvic Diaphragm, 170 

263. Perforations 171 

264. Internal Genitalia, 172 

265. The Vagina, 172 

266. The Uterus 178 

267. The Fallopian Tubes 184 

268. Ovaries 186 

269. The Parovarium, 191 



XVm TABLE OF CONTENTS. 

SECTION. PAGE. 

270. Urinary Organs and Rectum, 191 

271. The Urethra, 191 

272. The Bladder, 192 

273. The Ureters, 194 

274. The Rectum, 194 

275. Pelvic Peritoneum, 197 

276. Pelvic Connective Tissue, 200 

277. The Vascular Supply, 201 

278. The Lymphatic System, 208 

279. Consideration of the Pelvic Organs and Structure Studied as a Whole, 211 

PHYSIOLOGY. 

280. Functions, 212 

281. Puberty, 212 

282. Nubility, 213 

283. Menstruation and Ovulation 213 

284. Menopause, 221 

285. Copulation, 223 

286. Fecundation, 223 

MALFORMATIONS. 

287. Classification; Definition, 223 

288. Bifidities, 224 

289. The Degrees of Division, 224 

290. Double Uterus, 225 

291. Unequal Development of the Two Sides, ' 226 

292. Absent Uterus, 228 

293. A Rudimentary Uterus, 228 

294. Fetal and Infantile Uteri, 229 

295. Congenital Prolapsus Uteri, 230 

296. Accessory or Trifid Uteri, 230 

297. Absent or Rudimentary Tubes, . 230 

298. Accessory Tubal Ostia, 231 

299. Anomalies in Length, 231 

300. Absent or Rudimentary Ovaries, 231 

301. Supernumerary Ovaries 231 

302. Accessory or Constricted Ovaries, 231 

303. Displacements, 231 

304. Defects of Round or Broad Ligaments, 231 

305. Complete Absence or Rudimentary Development of the Vagina, 232 

306. Unilateral Vagina, 235 

307. Double Vagina, 235 

308. Atresia of the Genital Canal, 237 

309. Lateral Atresia, . . . : 240 

310. Absence of the Vulva, 241 

311. Infantile Vulva, 241 

312. Defects in Nymphae 241 

313. Defects of the Clitoris, 241 

314. Defects of the Hymen, 242 

315. Hermaphroditism, 243 

316. Gynandria, 244 

317. Androgyna, 245 

318. Atresia of the Urethra and Vagina, 246 

319. Hypospadias,. 246 

320. Epispadias, 246 

321. Duplication of the Bladder, 248 

322. Open Urachus, 249 

323. Irregular Exit of Ureter, 249 

324. Abnormal Communications, 249 



TABLE OF CONTENTS. XIX 



TRAUMATISMS. 

SECTION. PAGE. 

325. Injuries of the Genital Organs, 250 

326. External Violence, 250 

327. Coition, 251 

328. Parturition, 252 

329. Injuries of the Body of the Uterus, 253 

330. Injuries of the Cervix Uteri 254 

331. Symptoms of Laceration of the Cervix, 255 

332. Diagnosis 255 

333- Treatment, 257 

334. Complications, 257 

335. Trachelorrhaphy, 259 

336. Amputation of the Cervix, 261 

337. After-treatment, 263 

338. Lacerations of the Vagina, 263 

339. Fistulae, 264 

340. Etiology 264 

341. Symptoms, .' 265 

342. Diagnosis, 265 

343. Prognosis 267 

344. Treatment, 267 

345. Cauterization, 268 

346. Preliminary Treatment, 268 

347. Visicovaginal Fistula, 268 

348. Flap-splitting or Flap-sliding, 270 

349. Flap Formation, 275 

350. After-treatment, 277 

351. Closure of the Vagina; Colpocleisis; Episiostenosis, .• • • ■ 278 

352. Urethrovaginal Fistula, 279 

353. Vesico-uterine Fistula, 280 

354. Hysterostenosis or Hysterocleisis, 281 

355. Vesico-uterovaginal (Cervical) Fistula, 282 

356. Ureterovaginal-ureterocervical Fistulae, 283 

357. Accidents of the Operation and Results, 287 

358. Rectovaginal Fistula 289 

359. An Anovulvar Fistula, 290 

360. Preliminary and After-treatment, 290 

361. Enterovaginal Fistulse, 291 

362. Cervico-vaginal Fistula 291 

363. Lacerations of the Pelvic Floor, 291 

364. Causes, 292 

365. Degree or Extent, 293 

366. The Results 294 

367. Treatment 295 

368. By Primary Operation 296 

369. The Advantages of the Primary Procedure, 297 

370. Contraindications, 298 

371. The Intermediate Operation, 298 

372. Secondary Operation, 299 

373. After-treatment 323 

374. Choice of Operation, 325 

INFLAMMATIONS. 

375. The Recognition of the Development of the Genital Tract, 326 

376. Micro-organisms as a Cause 327 

377. Natural Protection against Infection, 327 

378. How Immunit}" is Lost 327 

379. Inflammation and Its Varieties 327 

380. The Causes of Inflammation 328 

381. Characteristics of Inflammation, 329 



XX TABLE OF CONTENTS. 

SECTION. PAGE. 

382. Classification of Inflammation, -^^o 

383. Vulvitis and Its Varieties, 331 

384. Causes, 331 

385. Vulvitis, Simple or Catarrhal, 332 

386. Follicular Vulvitis, 332 

387. Venereal Vulvitis, 332 

388. Eruptive Diseases of the Vulva, 334 

389. Phlegmonous Vulvitis, 335 

390. Diphtheric Vulvitis, ^^^ 

391. Diagnosis of Inflammatory Disease of the Vulva, 335 

392. Treatment, 336 

393. Edema and Gangrene, 338 

394. Bartholinitis, , 339 

395. Pruritus Vulvae, 341 

396. Kraurosis Vulv£e, ' 343 

397. Vaginismus, 345 

398. Vulvo- vaginitis, 347 

399. Vaginitis, Elytritis, or Colpitis, ; 348 

400. Varieties, 350 

401. Pathology, 350 

402. Etiology, 351 

403. Symptoms, '. 351 

404. Diagnosis, 352 

405. Prognosis, 353 

406. Treatment, 353 

407. Urethritis, 354 

408. Hyperemia, 354 

409. Acute Catarrhal Urethritis, 355 

410. Chronic Catarrhal Urethritis, 356 

411. Follicular Inflammation, 356 

412. Ulceration, 357 

413. Vesico-urethral Fissure, 357 

414. Diagnosis of Urethral Inflammations, 358 

415. Treatment of Urethral Inflammations, 359 

416. Cystitis, 361 

417. Symptoms of Acute Cystitis, 362 

418. Symptoms of Chronic Cystitis, 363 

419. Cystitis of Gonorrheal Origin, 363 

420. Tubercular Cystitis, 363 

421. Diagnosis of Cystitis, 363 

422. The Prognosis of Cystitis, 367 

423. Treatment, 368 

424. Ureteritis, 372 

425. Acute Ureteritis 372 

426. Chronic Ureteritis, 373 

INFLAMMATION OF THE CERVIX AND BODY OF THE 

UTERUS. 

427. Classification 374 

428. Endocervicitis, Chronic Cervical Catarrh, 375 

429. Causes, 379 

430. Symptoms 379 

431. Physical Signs 380 

432. Diagnosis 380 

433- Prognosis, 381 

434. Treatment, 381 

435. Acute Metritis and Endometritis, 384 

436. Pathologic Alterations 385 

437. Varieties and Their Source, 385 

438. Symptoms, 386 

439. Diagnosis, 387 



TABLE OF CONTENTS. XXI 

SECTION. PAGE. 

440. Prognosis, 389 

441. Treatment, 389 

442. Chronic Endometritis, 394 

443. Symptoms, 396 

444. Diagnosis, 397 

445. Treatment, 398 

446. Chronic Metritis, 400 

447. Etiology, 402 

448. Symptoms, 403 

449. Physical Signs and Diagnosis, 404 

450. Course and Prognosis, 405 

451. Treatment, 405 

452. Inflammation of the Fallopian Tube, 411 

453. Symptoms, 418 

454. Diagnosis, 419 

455. Prognosis 420 

456. Inflammation of the Ovary, 421 

457. Symptoms, ; 424 

458. Diagnosis, 425 

459. Treatment of Inflammation of the Appendages, 425 

460. Pelvic Inflammation, . . , 430 

461. Varieties, '. 430 

462. Pelvic Cellulitis, Parametritis, or Periuterine Phlegmon, 430 

463. Etiology, 432 

464. Symptoms 433 

465. Physical Signs, 433 

466. Diagnosis 436 

467. Prognosis 438 

468. Treatment, 438 

469. Pelvic Peritonitis, Perimetritis, Perisalpingitis, or Perioophoritis, .... 440 

470. Etiology 440 

471. Pathologic Anatomy, 444 

472. Symptoms, 446 

473. Diagnosis, 447 

474. Prognosis 448 

475. Treatment, 449 

DISPLACEMENTS OF THE PELVIC ORGANS. 

476. Changed Relations of Structures of Vulva, 466 

477. Physiologic Movements of the Uterus and the Forces by which it is 

Sustained, 467 

478. Pathologic Changes and What Constitute Them, 469 

479. Classification of Displacements, 471 

480. Ascent, 472 

481. Diagnosis, 473 

482. Descent, or Prolapsus, 473 

483. Etiology 475 

484. Symptoms 477 

485. Diagnosis, 481 

486. Prognosis 485 

487. Treatment, 488 

488. Urethrocele .• 499 

489. Dislocation of the Uterus, 500 

490. Diagnosis 500 

491. Torsion, 501 

492. Anteversion 501 

493. Etiology 502 

494. Symptoms 502 

495. Diagnosis 502 

496. Treatment, 502 

497. Retroversion, '. 504 



XXll TABLE OF CONTENTS. 

SECTION. PAGE. 

498. Etiology, 504 

499. Symptoms, 505 

500. Diagnosis, 506 

501. Lateral Version, 506 

502. Anteflexion, 506 

503. Etiology, 508 

504. Symptoms, 508 

505. Diagnosis, 509 

506. Treatment, 509 

507. Retroflexion, 514 

508. Etiology, 516 

509. Symptoms, 516 

510. Diagnosis, 518 

511. Treatment of Retroversion and Retroflexion, 520 

512. Lateral Flexion, 546 

513. Complications Associated with Displacements, . 546 

514. Prognosis of Displacements, 547 

515. General Treatment, 5-47 

516. Summar}^ 548 

517. Inversion of the Uterus, 550 

518. Etiology, 553 

519. Symptoms, 554 

520. Diagnosis 555 

521. Treatment, 557 

522. Displacements of the Appendages, 564 

523. Symptoms, 565 

524. Diagnosis, 565 

525. Treatment, 566 

GENITO-URINARY HEMORRHAGE. 

526. Hemorrhage a Symptom, 566 

527. Site and Varieties, 566 

528. Hematuria and Its Causes, 567 

529. Symptoms and Diagnosis, 567 

530. Treatment,. 568 

531. Genital Hemorrhage or Bleeding, 569 

532. Diagnosis, 570 

533. Treatment, 572 

534. Vulvar Hematoma or Hematocele, 573 

535. Vaginal Hematoma or Thrombus, 573 

536. Diagnosis, 575 

537. Treatment, 575 

538. Periuterine Hemorrhage, 576 

539. Causes, 576 

540. Symptoms, 577 

541. Extraperitoneal Hematocele, 578 

542. Symptoms, 578 

543. Diagnosis, 579 

544. Prognosis, 580 

545. Treatment, 580 

EXTRA-UTERINE PREGNANCY. 

546. Definition, 582 

547. Causes, 582 

548. Varieties, 584 

549. Course and Progress, 585 

550. Symptoms, 596 

551. Diagnosis 599 

552. Difi^erential Diagnosis, 604 

553. Prognosis 608 

554. Treatment, 609 



TABLE OF CONTENTS. XXUl 



GENITAL TUMORS. 

SECTION. PAGE. 

555. Definition 621 

556. Classification, • 621 

VULVA, VAGINA, AND BLADDER. 

557. Characteristics of Benign Neoplasms, 622 

558. Unclassified, 623 

559. Hernias, 623 

560. Hydrocele, 624 

561. Erectile or Vascular Tnmors, 625 

562. Urethral Caruncle, 626 

563. Varicose Veins, 628 

564. Edema, 628 

565. Elephantiasis 628 

566. Tiimors of the Vulva, . 629 

567. Serous Cysts, 629 

568. Sebaceous Cysts, 629 

569. Blood Cysts, 629 

570. Neuroma of the Vulva, 630 

571. Simple Vegetations, 630 

572. Fibroma and Myxoma, 633 

573. Lipoma, 633 

574. Enchondroma, 633 

575. Malignant Disease of the Vulva, 633 

VAGINA. 

576. Cysts of the Vagina, 637 

577. Fibroid Tumors and Polypi, , 638 

578. Papillomata, 639 

579. Malignant Neoplasms, 639 

BLADDER. 

580. Tumors of the Bladder, 642 

581. Mucous Polypi, 642 

582. Myoma, 643 

583. Carcinoma, 649 

UTERUS. 

584. Fibromyomatous Tumors, 650 

585. Pathologic Anatomy, 652 

586. Microscopic Appearance, 652 

587. Varieties, 653 

588. Submucous Fibroids, 654 

589. Interstitial, Mural, or Centric Fibroid Growths, 657 

590. Subperitoneal GroT^-ths, 660 

591. Fibromyoma of the Cervix, 662 

592. Etiology, 664 

593. Symptoms 667 

594. Diagnosis of M3^omata, 671 

595. Difterential Diagnosis of Myomata, 674 

596. Alterations and Degenerations, 681 

597. Mixed Growths: Enchondroma, Sarcoma, Osteoma, and Carcinoma, . 686 

598. Complications, 687 

599. (a) The Influence of the Myoma upon Conception, 690 

600. (b) The Influence of Pregnancy upon the Myoma, 691 

601. (c) The Influence of the Myoma upon Pregnancy, 692 

602. (d) Influence upon Labor, 693 

603. Course and Prognosis, 693 

604. Treatment 696 

605. (a) Medical Treatment, 697 



XXIV TABLE OF CONTENTS. 

SECTION. PAGE. 

606. (b) Electric, 700 

607. (c) Surgical, 704 

Vaginal Procedures: 

608. (i) Dilatation and Curetment of the Uterus, 705 

609. (2) Incision of the Cervix, 708 

610. (3) Incision of the Capsule, ' 708 

611. (4) Removal of the Growth, 709 

612. (5) Ligation of the Vessels, 715 

613. (6) Hysterectomy, 716 

Abdominal Route: 

614. (7) Castration, 718 

615. (8) Ligation of the Vessels, 719 

616. (9) Myomectomy .' 720 

617. (10) Enucleation, 720 

618. (11) Partial Hysterectomy, or Supravaginal Amputation of the 

Uterus, 723 

619. (12) Panhysterectomy, 729 

620. Summary, 734 

621. Accidents during Operation, 737 

622. Causes of Death Following Hysterectomy, 740 

623. Puerperal Tumors; Physometra, 741 

624. Hydrometra, 742 

625. Hematometra, 742 

626. Pyometra, 742 

627. Hydatid Cysts of the Uterus, 742 

628. Mucous Polypi of the Uterus, 742 

629. Malignant Tumors, 743 

630. Classification, 744 

631. Anatomic Classification of Carcinoma, 744 

632. Development of Squamous-cell Carcinoma, 746 

633. Histology of Squamous-cell Carcinoma , 748 

634. Adenocarcinoma of the Cervix, 749 

635. Histology of Adenocarcinoma, 751 

636. Adenocarcinoma of the Body, 752 

637. Histology of Adenocarcinoma of the Body of the Uterus, 754 

638. Dissemination of Carcinoma, 756 

639. Clinical Forms, 762 

640. Etiology, 764 

641. Symptoms, 767 

642. Physical Signs, 772 

643. Complications, 773 

644. Diagnosis, 775 

645. Duration of Cancer, 781 

646. Prognosis, 782 

647. Treatment, 783 

648. (A) Operable. — Partial Vaginal Operations, 784 

649. Total Extirpation of the Uterus, 786 

650. Vaginal Hysterectomy, 790 

651. Accidents of Vaginal Total Extirpation, 797 

652. Abdominal Hysterectomy, 799 

653. Comparative Advantages of the Two Proceedings, 805 

654. The Sacral Method, 806 

655. The Perineal Method, 813 

656. The Mortality of Abdominal and Vaginal Operations, 814 

657. Duration of Recovery, 814 

658. Recurrence, 815 

659. (B) Inoperable, 818 

660. Pregnancy Complicating Carcinoma 829 

661. Summary, 830 

662. Chorio-epithelioma Malignum, 832 



TABLE OF CONTENTS. XXV 



663. Endothelioma Uteri, 835 

664. Sarcoma Uteri, 836 

665. Varieties, 836 

666. Pathology, 836 

667. Etiology, 841 

668. Symptoms, 842 

669. Duration, 845 

670. Diagnosis, 846 

671. Recurrence, 849 

672. Treatment, 850 

673. Treatment Following Operations for MaUgnant Disease, 850 

FALLOPIAN TUBES. 

674. Tumors (Benign), 852 

675. Fibroma or Myoma, 852 

676. Fibrocyst, 853 

677. Enchondromata, 853 

678. Dermoid of the Tube, 853 

679. Cysts of Small Size, 853 

680. Polypus, 854 

681. Papillomata, 854 

682. Malignant Tumors, 855 

683. Sarcoma, 855 

684. Chorio-epithelioma Malignum, 856 

BROAD LIGAMENTS. 

685. Cysts of the Broad Ligament, 856 

686. Echinococcus Cysts, 857 

687. Parovarian Varicocele; Phleboliths, 858 

688. Lipomata, 858 

689. Fibroma, 858 

690. Malignant Growths, 858 

OVARIAN TUMORS. 

691. Characteristics, 859 

692. Classification, 859 

693. Small Residual Cysts, 861 

694. Simple or Follicular Cysts; Hydrops Folliculorum, 862 

695. Cysts of the Corpus Luteum, 863 

696. Tubo-ovarian Cysts, 863 

697. Glandular Proliferating Cysts, 864 

698. Pedicle, 865 

699. Structure, 868 

700. Papillary Proliferous Cysts, 872 

701. Dermoid Cysts 873 

702. Parovarian Cysts, 875 

703. Solid Ovarian Tumors, 876 

704. Fibromyoma, 876 

705. Sarcoma of the Ovary, 877 

706. Carcinoma of the Ovary, 877 

707. Endothelioma of the Ovary, 878 

708. Etiology, 878 

709. Natural Progress, 879 

710. Symptoms, 880 

711. Complications, 880 

712. Degenerative Changes in the Cyst-walls, 887 

713. Diagnosis, 888 

714. Exploratory Puncture, 901 

715. Exploratory Incision, 902 

716. Treatment 902 

717. Ovariotomy, 903 



XXVI TABLE OF CONTENTS. 

SECTION. PAGE. 

718. Indications, 903 

71Q. Contraindications, 904 

720. General Considerations, 905 

721. Operation, 906 

722. Incomplete Operation, 916 

723. Rupture of the Cyst 917 

724. Hemorrhage, 918 

725. Visceral Injuries, 918 

726. Prognosis, 920 

727. Intestinal Complications, 921 

728. Causes of Death 922 



List of Authors Quoted •. . ; 923 

Index, 929 



I Ik 



LIST OF ILLUSTRATIONS 



FIG. . PAGE. 

1. Chadwick Table, 23 

2. Dorsal Position, 24 

3. Sims' Position. Proper Method of Holding the Speculum, 25 

4. Genupectoral Position. Organs Shown in Outline, 25 

5. Trendelenburg Position, 26 

6. Proper Position of Fingers for Examination, 28 

7. Half Section of the Pelvis with Patient Erect, Showing Normal Posi- 

tion of Uterus (Deaver), 29 

8. Bimanual Examination, 31 

9. Recto-abdominal Palpation, 32 

10. Recto-vagino-abdominal Palpation. Index Finger of One Hand in 

the Rectum, Thumb in the Vagina, and the Fingers of the Other 

Hand over the Abdomen, 33 

11. Rectovesical Palpation. Sound in Bladder, 34 

1 2 . Simpson's Sound, 35 

13. Sims' Probe, 35 

14. Whalebone Probe, 35 

15. Spring Probe Covered with Rubber, 35 

16. Introduction of the Sound, 36 

1 7- Ferguson's Speculum, 37 

18. Milk-glass Specula, 38 

19. Nott's Speculum, 38 

20. Higbee's Specula (three sizes), 39 

21. Talley's Speculum, , 39 

22. Goodell's Speculum, 39 

23. Sims' Speculum, 40 

24. Proper Method of Holding Sims' Speculum. The Cervix Brought 

into View with the Tenaculum, 40 

25. Sims' Depressor, 41 

26. Goodell's Tenaculum, 41 

27. Self-retaining Sims' Speculum, 41 

28. Simon's Retractors, 42 

29. Edebohls' Speculum, 42 

30. Edebohls' Speculum in Position 42 

31. Double Tenaculum Forceps, 43 

32. Traction upon Uterus with Double Tenaculum during Digital Exam- 

ination by the Rectum, 43 

2,s- Hollow Laminaria Tent, 44 

34. Uterine Forceps — Dressing, 44 

35. Dilated Tent Showing Constriction from Internal Os (Thomas), 45 

36. EUinger's Dilator, 45 

37. Goodell's Modification of Ellinger's Dilator, 45 

38. Pratt's Dilators, 46 

39. The Method of Dilatation with the Graduated Bougies, 47 

40. Kuchenmeister's Scissors, 47 

41. Douche Curet, 49 

42. Tissue removed by Test Curetment, 51 

43. Cabinet with Trays and Card Index for the Preservation of Slides 59 

44. Coplin's Method of Indexing and Preserving Slides 60 

45. Same as Fig. 44 Folded with Slide Enclosed, 60 

46. Staphylococcus Pyogenes Aureus (CopUn), 64 

xxvii 



XXVni LIST OF ILLUSTRATIONS. 

FIG. PAGE. 

47. Streptococcus Pyogenes (Coplin), 64 

48. Secretion from Gonorrheal Vaginitis, Showing Gonococci, 65 

49. Secretion of Simple Vaginitis Showing Various Forms, 66 

50. Bacillus Coli Communis (Coplin), 68 

51. Bacillus Tuberculosis (Coplin), 68 

52. Needle for Puncturing Finger, 77 

53. Hematocytometer, 81 

54. Dare's Hemoglobinometer, 82 

55. Tallqvist Hemoglobin Scale, 82 

56. Needle for Securing Blood, 91 

57. Skene's Urethroscope, 94 

58. Cystoscopes, 94 

59. Kelly's Specula (Urethra), 95 

60. Mouse-tooth Forceps for Cotton Pledgets, 95 

61. Kelly's Evacuator, 95 

62. 63. Ureteral Catheters. Metal and Soft, 95 

64. Harris' Double Catheter for Obtaining Urine from Kidneys Separately, 96 

65. Abdomen Prepared for Examination, 97 

66. Nest of Trocars, 100 

67. Aspirator, 10 1 

68. Arnold Steam Sterilizer, 103 

69. Steam-pressure Sterilizer, 104 

70. Sterilizer for Boiling Instruments, 104 

71. Gauze Pads, 105 

72. Irrigating Glass Tube. Open End, 112 

73. White's Oxygen Apparatus, which can be Utilized for Anesthesia by 

Placing Anesthetic in the Bottle, 116 

74. Northrup's Apparatus for Administering a Mixture of Chloroform 

and Oxygen, 116 

75. Arrangement of Tables and Assistants in Operating Room, 121 

76. Abdominal Wall Incised; Peritoneum Picked up by Dissecting For- 

ceps, 122 

77. Peritoneum Incised, 122 

78. Crescent Incision Exposing Aponeurosis, 123 

79. Aponeurosis Excised, Showing Pyramidalis Muscles, 123 

80. Scalpels, 124 

81. Pressure Forceps, 124 

82. Dissecting Forceps — Long Bladed, 125 

83. Glass Drainage-tubes, 126 

84. Uterine Syringe for Cleaning Drainage-tube, 126 

85. Tube Forceps for Cotton Pledgets, 126 

86. Gauze Wick in Drain, 127 

87. Mikulicz Drain, 127 

88. Gauze Drain Covered w4th Rubber Tissue, 128 

. 89. Curved and Straight Needles, 129 

90. Needle Forceps, 129 

91. I. Peritoneum Nearly Closed with Continuous Catgut. 2. Silkworm- 

gut Sutures through All Structures above Peritoneum. 3. 

Aponeurosis being United with Continuous Suture of Catgut, .... 130 

92. Silkworm-gut Sutures Tied, 130 

93. Butt Uterine Scarifier, 144 

94. Aluminium Uterine Applicator, 145 

95. Long Glass Pipet, 145 

96. Insufflator — Straight Stem, 146 

97. Tampon, 146 

98. Position of the Fingers in Pelvic Massage, 148 

99. Portable Galvanic Battery with Galvanom.eter, 150 

100. Intra-uterine Electrode w4th Movable Insulating Cover, 151 

10 1. Vaginal Electrodes of Different Sizes, 151 

102. Faradic Battery, 153 

103. Bipolar Uterine Electrode, 154 

104. Vaginal Electrode — Bipolar, 154 



LIST OF ILLUSTRATIONS. XXIX 

FIG. PAGE. 

105. Human Embryo at end of Thirty-five Days {Coste), 157 

106. Coalescence of Miiller's Duct, 158 

107. 108, 109. Progress of Development of the Genitalia, 158 

no. Virgin Vulva: Labia not Separated (Deaver), 160 

111. Virgin Vulva: Labia Separated, Showing the Hymen Unruptured 

(Deaver), 161 

112. Hymen Crescens, 162 

113. Hymen Annularis, 162 

114. Hymen Serratus, 163 

115. Hymen Infundibularis, 163 

116. Hymen Biseptus, 164 

117. Hymen Cribriformis, 164 

118. Laceration of the Hymen, 165 

119. Muscles of the Female Perineum (Deaver), 166 

120. The Under Surface of the Levator Ani Muscle (Deaver), 171 

121. The Upper Surface of the Levator Ani Muscle (Deaver), 172 

122. A Mesial Section: the Body Erect (Deaver), 173 

123. A Mesial Section: the Body Recumbent, 174 

124. Arteries and Nerves of the Female Perineum (Savage), 175 

125. Anterior Wall of Vagina Showing Columnae Rugarum (Byford, after 

Savage), 176 

126. Horizontal Section of the Vagina and Urethra of an Infant, 177 

127. Median Section of Uterus from Side to Side through the Fallopian 

Tubes. Mode of Junction of Vagina and Uterus (Savage) 179 

128. Virgin Uterus. Median Section (Byford, after Sappey), 181 

129. Mucous Membrane of Uterine Body Showing Follicles (Alann), 181 

130. Section of Normal Endometrium, 182 

131. Virgin Os and Cervix (Sappey), 183 

132. Section of Fallopian Tube through the Isthmus, 185 

133. Section of Tube through the Ampulla near the Isthmus, 186 

134. Section of Ovary, Showing Graafian Follicles (Wyder), 188 

135. Large Corpus Luteum in Association with an Ovarian Dermoid. Re- 

moved from an Unmarried Woman who had Never Been Pregnant 

(Sutton), 190 

136. Vesicovaginal Septum and Base of Female Bladder. Anatomic Re- 

lations of Ureters at Their Entrance into the Bladder. Contents 

of Alar Ligament (Savage), 193 

137. Superior View of the Pelvic Cavity (Deaver), 196 

138. Curved Dotted Line Shows Covering of the Anterior Uterine Wall by 

Peritoneum (Winter), 198 

139. Posterior Surface of Uterus Showing Extent of Peritoneum; also Fal- 

lopian Tubes, Ovaries, and Ovarian Ligaments (Winter) 198 

140. Vertical Transverse Section of the Pelvis, Showing Peritoneal Pouches 

(Liischka), 199 

141. Distribution of the Uterine and Ovarian Vessels, 202 

142. Arteries of the Female Pelvic Organs (Savage), 203 

143. Distribution of the Pudic Artery to the Structures of the Perineum 

(Deaver), 204 

144. Relation of the Urethral and Vaginal Venous Plexuses to the Veins 

of the Clitoris and Bulb; The Right Side of the Pelvis Re- 
moved by a Section in Front, through the Pubic Body, About 
an Inch from the Symphysis, and, Behind, through Sacro-iliac 

Joint (Savage), 205 

145. Veins and Erectile Venous Plexuses of the Female Pelvis (Savage), . . 206 

146. Erectile Organs and Veins of the Female Perineum (Savage), 207 

147. The Lumbo-iliac Lymphatics and Glands. Lymphatics of the 

Gravid Uterus and Appendages (Savage) 208 

148. Nerves of the Unimpregnated Uterus with the Nerves of the Clitoris 

(Savage), ' 210 

149. Changes of Uterine Mucous Membrane during Menstruation (Wyder), 216 

150. Degrees of Division of the Genital Tract, 224 

151. Uterus Bicornis (Auvard), 224 



XXX LIST OF ILLUSTRATIONS. 

FIG. PAGE. 

152. Uterus Bicornis Unicollis (Am. Sys. Gyn.) , 225 

153. Uterus Bifidus (Auvard), 226 

154. Uterus Didelphys (Am. Sys. Gyn.), 226 

155. Uterus Unicornis (Auvard), 227 

156. Atresia of Rudimentary Horn with an Accumulation of Menstrual 

Blood (Auvard), 227 

157. Uterus Bipartitus or Duplex (Byford), 228 

158. Uterus Biseptus (Courty), 229 

159. Absent Vagina, 232 

160. Line of Incision for Formation of Flaps, i, 2. Flaps from Labia 

Minora which are Split and Used to Line the Vagina, 233 

161. Flaps Outlined in Fig. 160 Sutured in Place, and Denuded Surfaces 

which have Furnished Flaps to Line Posterior Wall, 234 

162. Sims' Glass Dilator, 235 

163. Double Vagina (Photograph taken from patient of Dr. J. M. Fisher),. . 236 

164. Imperforate Hymen, 237 

165. Hematocolpos, 238 

166. Hematometra, 239 

167. Hematocolpometra, 240 

168. Enlarged Clitoris, 242 

169. Apparent Hermaphroditism — (American Journal of Obstetrics), 244 

170. External Genital Organs of Madame Le Fort (Auvard), 244 

171. Outline of Internal Organs of Madame Le Fort (Auvard), 245 

172. Androgyna (Pozzi), 246 

173. Imperforate Anus. Communication between Rectum and Vagina, . . 247 

174. Congenital Defect of Vagina. Communication with the Rectum 247 

175. Congenital Absence of the Urethra. Communication of Bladder 

with the Vagina, 248 

176. Communication of Rectum and Bladder with the Vagina, 248 

177. Suprapubic Opening of Vagina and Urethra, 249 

178. Knives for Denudation, 252 

179. Curved Scissors,. 252 

180. Retractor, 252 

181. Blunt Hook, 253 

182. Needle-holder 253 

183. Needles, 253 

184. Needle with Loop for Suture, 253 

185. Slight Fissure of Cervix, 255 

186. Extensive Laceration of Cervix (Munde), 255 

187. Bilateral Laceration of Cervix (Munde), 256 

188. Slight Stellate Laceration of Cervix (Munde), 256 

189. Extensive Stellate Laceration of Cervix (Munde), 256 

190. Laceration of Cervix with Hypertrophy and Eversion of Cervical 

Mucous Membrane (Munde), 256 

191. Blunt and Sharp Curets, 258 

192. Edges of Laceration Turned by Tenaculum Hooked into Each Lip,. . 259 

193. Denudation of Lacerated Cervix, 260 

194. Surfaces Denuded Ready for Union, 260 

195. Sutures Introduced, 260 

196. Sutures Tied, 260 

197. Double Flap Amputation of the Cervix (Auvard), 261 

198. Sutures Introduced (Auvard) 261 

199. Wound Closed, 261 

200. Schroder's Single Flap Operation, 262 

201. Schroder's Operation Completed, 263 

202. Scheme Showing Various Fistulas, 265 

203. Large Vesicovaginal Fistula with Prolapse of the Anterior Vesical 

Wall through the Opening, 266 

204. Denudation of the Edges of the Fistula, 267 

205. Sutures Introduced, 268 

206. Wound Closed, 269 

207. Method of Suturing to Decrease the Tension upon the Sutures, 270 



LIST OF ILLUSTRATIONS. XXXI 

FIG. PAGE. 

208. Showing Continuation of Suturing to Close Fistula with Incisions to 

Decrease Tension with Suture Introduced on Left Side to Close 

the Secondary Opening 271 

209. Wound Closed, 271 

210. Fistula Preparatory to Splitting into Vesical and Vaginal Flaps, 272 

211. Demonstration of Flap-splitting, 272 

212. Suture Introduced into Vesical Flap, 273 

213. Suture Tied in Vesical Flap Introduced in Vagina, 273 

214. Wound Closed, .' 273 

215. Sutures Introduced to Close Vesical Surface, as Suggested by Wal- 

cher, 274 

216. Flap-formation as Suggested by Ferguson, 275 

217. Flap Turned in and Vesical Opening Closed, 276 

218. Introduction of Vaginal Sutures, 277 

219. Section Showing Projection upon Vesical Surface, 278 

220. Self -retaining Catheter, 278 

221. Vesico-uterine Fistula, 278 

222. Colpocleisis, 279 

223. Closure of Fistula after Its Exposure by Incision through Anterior 

Vaginal Fornix, 280 

224. Fistula Closed into Vagina. Uterine Opening Remains, Which Will 

Close of Itself 281 

225. Section Showing Suture for Hysterocleisis, 281 

226. Closure of Fistula within Cervical Canal after Splitting Cervix, 282 

227. Hysterocleisis, 283 

228. Anterior Lip of Cervix Utilized to Close the Fistula, 284 

229. Vesico-uterovaginal Fistula in which the Posterior Lip of the Uterus 

is Utilized to Close the Opening, ■ 284 

230. Vesical Wall Loosened and Sutured. Vaginal Wall Sutured in Oppo- 

site Direction, 285 

231. Operation for Ureterovaginal Fistula, 286 

232. Vaginal Implantation of the Ureter into the Bladder, 287 

233. Abdominal Transplantation of Ureter for Ureterovaginal Fistula,. ... 288 

234. Ureteral Anastomosis, 289 

235. Sagittal Incision for Rectovaginal Fistula, 290 

236. Lauenstein Suture in Rectovaginal Fistula through Rectal Wall,. .... 290 

237. Rectal Wall Closed by Transverse Line of Sutures; Vaginal by Ver- 

tical Line of Sutures, 291 

238. Rectovaginal Fistula Closed in Operation of Perineorrhaphy, 292 

239. Rupture of Perineum into Rectovaginal Septum, 293 

240. Cystocele, 294 

241. Rectocele, 295 

242. Right and Left Curved Scissors, 296 

243. Incomplete Rupture of the Perineum, 297 

244. Simon-Hegar Method of Denudation, 297 

245. Sutures Introduced to Close the Wound, 298 

246. Garrigues' Modification of the Hegar Operation, 299 

247. Upper Part of the Wound Closed; Last Sutures Introduced, 300 

248. Wound Completely Closed, 300 

249. Lauenstein Suture, 301 

250. Rectum and Vagina Closed with Lauenstein Suture, 301 

251. Hildebrandt's Method of Suturing, 302 

252. Hildebrandt Suture Closed, 303 

253. Heppner's Figure-of-8 Suture, 304 

254. Martin Suture to Close the Rectal Opening, 305 

255. Martin Suture Continued, 305 

256. Denudation for Freund's Operation, 306 

257. Sutures Inserted in Rectal Wall and Lateral Vaginal Angles, 307 

258. Vaginal Angles and Rectal Wall Closed. Suture in Place for Peri- 

neum, 307 

259. Denudation Completely Closed, 307 

260. Emmet's Operation, Surface Denuded and Lateral Sutures in Place, 308 



XXXll LIST OF ILLUSTRATIONS. 

FIG. PAGE. 

261. Emmet's Operation. Lateral Angles Closed and Perineal Suture 

Introduced, 309 

262. Emmet's Operation Completed, 310 

263. Emmet's Operation for Complete Laceration, 310 

264. Suture to Unite the Ends of the Sphincter, 310 

265. Outerbridge's Suture, 311 

266. Cleveland's Suture, 312 

267. Dudley's Operation with Interrupted Sutures, 312 

268. Dudley's Operation Completed, 313 

269. Denudation for Martin's Operation, 313 

270. Vaginal Surfaces United; Perineal Sutures in Place, 314 

271. Bischoff's Operation, 314 

272. Splitting Vaginal Wall Preparatory to Suture (Andrews), 315 

273. Introduction of Suture in Retracted Flap (Andrews), 316 

274. Suture Tied; the remaining Surface to be Closed by Transverse Su- 

tures (Andrews), 317 

275. Incision for Tait's Operation for Incomplete Laceration, 318 

276. Line of Incision for Tait's Operation for Complete Laceration, 319 

277. Appearance of Surface after Formation of Flaps, 319 

278. Outline of Flap to be Turned down to Form Raw Surface for Union. 

Flap thus Formed to Protect from Fecal Infection (Ristine), 320 

279. Flap Turned down. Sphincter Closed and Sutures Introduced (Ris- 

tine) , 321 

280. Outline for Simpson's Operation, 322 

281. Sutures Introduced in Simpson's Operation, 323 

282. Denudation for Fritsch's Operation, 324 

283. Catgut Sutures for Union of the Rectal Wall, 325 

284. Incision for Duke's Operation, 325 

285. Incision Separated in Vertical Direction, 326 

286. Incision United by Transverse Sutures, 326 

287. Follicular Vulvitis (Thomas and Munde), ;^;^;^ 

288. Cyst of Bartholin's Gland (Auvard), 339 

289. Kraurosis Vulvse, 344 

290. Urethra Laid Open with Probes, Distending Skene's Glands, Poste- 

rior Wall Divided (Byford, after Skene) , 357 

291. Reflux Catheter, . 361 

292. Double-current Catheter, 371 

293. Simple Papillary Erosion of the Cervix, 376 

294. Simple Papillary Erosion with Enlarged Follicles, 376 

295. Extensive Cystic Disease of the Cervix, 377 

296. Chronic Endocervicitis, 378 

297. Lines of Incision for Contracted or Pinhole Os (Thomas and Munde), 382 

298. Union of Vaginal and Cervical Mucous Membranes, 382 

299. Interstitial Endometritis, 393 

300. Hypertrophic Glandular Endometritis, Showing Increase in Size and 

Numbers of Glands, 394 

301. Hypertrophic Glandular Endometritis, Vertical Section through the 

Mucous Membrane, 395 

302. Polypoid Masses Associated with Chronic Endometritis, 396 

303. Membranous Dysmenorrhea, 397 

304. Uterus Dilated with Graduated Bougies, 409 

305. Uterine Cavity Packed with Gauze after Dilatation, 410 

306. Acute Salpingitis, 412 

307. Chronic Salpingitis Showing Agglutination of Folds, 413 

308. Extensive Pus Collections with General Adhesions, 413 

309. Pyosalpinx, 4^4 

310. Section from Wall of Pus Tube 415 

311. Single Fold from Wall of Pus Tube Enlarged 415 

312. Distended Pus Tubes Removed from Young Girl, 416 

313. Convoluted Fallopian Tube from Perisalpingitis, 417 

314. Incomplete Inflammatory Closure of the Fallopian Tube. Portions 

of Fimbriae Unretracted, 417 



LIST OF ILLUSTRATIONS. XXXlll 

FIG. PAGE. 

315. Double Tubo-ovarian Collection, 418 

316. Hydrosalpinx, 419 

317. Double Pyosalpinx Showing Adhesions to the Rectum, to the Uterus, 

and on the Right to the Appendix, 420 

318. Peri-oophoritis. Tube and Ovary Encysted, 423 

319. Resection of Tube, 428 

320. Operation of Resection of Tube Completed, 428 

321. Exudation in Broad Ligament from Pelvic Cellulitis, 434 

322. Exudation of Cellulitis over Rectum, 435 

323. Induration from Peritonitis, 449 

324. Induration from Pelvic Cellulitis, 450 

325. Intestines Held Back by Gauze. Patient in Trendelenburg Posture,. 454 

326. Three-pronged Vulsellum, 456 

327. Vaginal Incision for Pus Collection in the Broad Ligament, 457 

328. Incision through Vagina with Thermocautery in Vaginal Excision of 

the Uterus, 458 

329. Clamp Forceps for Securing the Broad Ligament, 459 

330. Deschamps Needle Ligature Carrier, 459 

331. Drawing down the Fundus {Landau), 460 

332. Application of the Clamp Forceps to the Lower Portion of the Broad 

Ligament {Landau), 461 

7,7,7,. Ligation of the Broad Ligament in Vaginal Hysterectomy, 462 

334. Upper Portion of the Broad Ligament Secured by Clamp Forceps 

{Landau) , 463 

335. The Introduction of Gauze after the Rem.oval of the Uterus, 464 

336. Closure of the Vaginal Wound by Sutures, 465 

337. Landau's Method of Delivering the Uterus after Its Complete Median 

Section, 466 

338. Uterus Displaced by Distended Bladder, 467 

339. Uterus Displaced by Impacted Rectum, 468 

340. Scheme of Dislocated Uteri {Dudley) 469 

341. Uterus pushed up by Tumor in Douglas' Pouch, 470 

342. Uterovaginal Prolapse, 471 

343. Vagino-uterine Prolapsus, 472 

344. Vagino-uterine Prolapsus with Hypertrophic Elongation of the Cervix 

{Auvard), 473 

345. Uterus Detached Showing Hypertrophic Elongation of the Cervix 

{Auvard), 474 

346. Vulvar Appearance of Vagino-uterine Prolapsus, 475 

347. Pseudoprolapsus. Cervix within the Vagina, 476 

348. Pseudoprolapsus. Cervix Protruding from the Vulva, 477 

349. Anterior and Posterior Colpocele, 478 

350. Cystocele, 47p 

351. Prolapsus with Both Rectocele and Cystocele, 480 

352. Irreducible Prolapsus. The Tumor Contained Uterus and a Large 

Pyosalpinx. Ulceration of the Cervix 481 

353. Prolapsus without Protrusion of the Vaginal Walls, 482 

354. Determination of the Position of the Uterus by Bimanual Palpation, 483 

355. Recognition of the Uterus with Thumb and Fingers of One Hand, . . . 484 

356. Diagnosis of Position of the Uterine Body by Rectal Touch, 485 

357. Hypertrophic Elongation of the Cervix. Anterior Vagina Everted, 

while Posterior Retains Its Normal Position {Auvard), 486 

358. Enterocele through the Posterior Vaginal Fornix, 487 

359. Vagino-uterine Prolapse Complicated by Proliferating Epithelioma,. . 488 

360. Ring Pessary, 490 

361. Disc Pessary, 490 

362. Smith-Hodge Pessary, 490 

363. Munde Pessary, 490 

364. Hoffman Soft-rubber Pessary, 491 

365. Zwank Pessary, 491 

366. Gehrung Pessary, . 491 

367. Hewitt Cradle Pessary, 491 



XXXIV LIST OF ILLUSTRATIONS. 



PAGE. 



368. Anterior Colporrhaphy. Anterior Vaginal Wall Removed , 493 

369. Wound Closed, 494 

370. Stolz's Purse-string Suture (Pozzi), 495 

371. First Stage of Dudley's Bilateral Denudation of the Vaginal Walls 

for Prolapsus (Dudley), 497 

372. Dudley's Operation Showing Denudation upon One Side of the Vagina 

(Dudley), 498 

373. Urethrocele, 499 

374. Anteversion of the Uterus, 501 

375. Sims' Operation for Anteversion (Auvard) 503 

376. Abdominal Belt, 504 

377. Retroversion, 505 

378. Slight Degree of Anteflexion, 507 

379. Acute Anteflexion, 507 

380. Thomas Anteflexion Pessary, ' 510 

381. Stem Pessary, 510 

382. Section Showing Thinning of Cervical Walls at the Angle of Flexion, 511 

383. Anteflexion Associated with Contraction of Uterosacral Ligaments,. . 511 

384. Dudley's Operation for Anteflexion, by Incising and Suturing the 

Posterior Lip (Dudley) , 513 

385. Completion of Dudley's Operation, by Transverse Denudation and 

Suturing of the Anterior Lip, 514 

386. Nourse's Operation by Splitting the Cervix and Resuturing the In- 

cisions, 515 

387. Operation Completed, 515 

388. Retroflexion of Slight Degree, 516 

389. Retroflexion of Extreme Degree, 517 

390. Retroflexion Following Version, 517 

391. Retroflexion Produced by Fibroma of Anterior Uterine Wall, 518 

392. Retroflexion the Sequel of Inflammatory Adhesions (Thomas and 

Munde), 518 

393. Retroflexion Simulated by Posterior Uterine Myoma, 519 

394. Retroflexion Simulated by Small Ovarian Cyst in Posterior Culdesac, 519 

395. Anteflexion and Retroflexion Simulated by Pelvic Exudation, 520 

396. The Retroverted Uterus Replaced; Patient in Dorsal Position, 521 

397. Schultze's Method of Replacing an Adherent Retroverted Uterus,... . 522 

398. Second Step in Replacing Uterus by Schultze's Operation, 523 

399. Schultze Pessary, 525 

400. Proper Position of the Pessary, 525 

401. Faulty Position of the Pessary, 526 

402. Schultze's Sledge Pessary, 527 

403. Alexander Operation: Round Ligament Exposed (Edebohls), 528 

404. Round Ligament Being Drawn out (Edebohls), 529 

405. Round Ligament Sutured (Edebohls), 530 

406. Continuous Catgut Suture Uniting Internal Oblique Muscle to Pou- 

part's Ligament (Edebhols), 531 

407. Return Layer of Suture Bringing External Oblique Muscle in Apposi- 

tion (Edebohls), 532 

408. Wylie's Operation for Shortening the Round Ligaments within the 

Abdomen (Am. Sys. Gyn.), 533 

409. Mann's Operation for Intra-abdominal Shortening of Round Ligaments 

(Am.. Sys. Gyn.), 534 

410. Dudley's Operation of Desmopycnosis (Am. J. Obs.), 535 

411. Dudley's Operation Completed (Am. J. Obs.), 535 

412. Gilliam-Ferguson Operation. Round Ligament Seized through 

Stab Wound, 536 

413. Round Ligament Drawn through the Abdominal Wall, 537 

414. Section Showing Position of the Uterus with Completion of the 

Operation 537 

415. First Step in my Modification of the Gilliam Operation for securing 

Round Ligament Support, 538 



LIST OF ILLUSTRATIONS. XXXV 

FIG. PAGE. 

416. Second Step, Showing Ligament Fixed with Hemostat while Tempo- 

rary Ligature is Carried Beneath Anterior Leaflet of Broad Liga- 
ment with a Deschamps Needle, 539 

417. Operation Completed. Differs from Gilliam-Ferguson in having no In- 

ternal Sutures, 540 

418. Sutures Introduced for Ventro-suspension, 541 

419. Partial Inversion of the Uterus, Showing Three Degrees {Auvard),. . . 551 

420. Intravaginal Inversion; Three Degrees (Auvard), 551 

421. Extravaginal Inversion; Three Degrees (Auvard), 552 

422. Nonpuerperal Inversion. Fibroid Tumor Attached to the Fundus 

Uteri, •. 552 

423. Palpation of an Inversion of the First Degree (Auvard), 553 

424. Palpation of an Inversion of the Second Degree (Auvard), 554 

425. Appearance of Inversion of the Third Degree, 555 

426. o. Inversion of the Uterus, b. Fibroid Polypus, c. Fibroid Poly- 

pus, with Stenosis of the Cervical Canal, 556 

427. a. Submucous Fibroma, b. Partial Inversion, c. Partial Division 

of the Uterus, 557 

428. Prolapsus Uteri without Inversion, 558 

429. Inversion of the Uterus, Extravaginal, 558 

430. Central Taxis (Auvard), 559 

431. Lateral Taxis (Auvard), 560 

432. Peripheral Taxis (Attvard), 561 

433. The Use of the Air Pessary to Reduce an Inversion (A^ivard), 561 

434. Reduction of Inversion with White's Apparatus (Thomas) 562 

435. Intraperitoneal Dilatation of the Uterus (Thomas), 563 

436. Incision of the Posterior Uterine Wall PreHminary to Reduction of an 

Inversion, 564 

437. Prolapsus of Ovary and Tube behind Uterus, 565 

438. Intraperitoneal Hemorrhage (Auvard), 577 

439. Extraperitoneal Hematoma (Courty) 578 

440. Tubal Pregnancy (Sutton), 584 

441. Tubo-ovarian Pregnancy, 585 

442. Tubo-uterine or Interstitial Pregnancy, 585 

443. Tubal iVbortion, 586 

444. Complete Rupture of a Tubal Sac, 592 

445. Incomplete Rupture of Gestation Sac, 592 

446. Ectopic Gestation Sac Ruptured Showing Fetus, 601 

447. Large Ectopic Gestation Sac, 605 

448. Anterior Labial or Inguinal Hernia, 624 

449. Posterior Labial Hernia, 625 

450. Urethral Caruncle, 626 

451. Prolapsus Urethrse, 627 

452. Varicose Veins of the Vulva (Dr. W. Krusen), 628 

453. Vulvar Vegetations, 631 

454. Elephantiasis of the Vulva, 632 

455. Fibroid of Labium, 633 

456. Cancer of the Vulva, 634 

457. Appearance of the Vulva after an Operation for Cancer of the Vulva, 635 

458. Cysts of the Vagina, 638 

459. Myoma of the Anterior Vaginal W^all (Dr. J. C. Da Costa), 639 

460. Primary Cancer of the Vagina, 640 

461. Microscopic Section; Myoma Uteri (Coplin), 653 

462. Liomyoma of the Uterus (Coplin) 654 

463. Submucous Myoma (Polypoid), 655 

464. Sessile Submucous Myoma, 656 

465. Submucous Myoma Occupying Uterine Cavity, 656 

466. Submucous Myoma Extruded into the Vagina, 657 

467. Voluminous Myomata Occupying Anterior and Posterior Walls 

(Auvard), 658 

468. Circumscribed Interstitial Myomata (Auvard), . 659 

469. Local Interstitial Myomata (Auvard), 659 



XXXVl LIST OF ILLUSTRATIONS. 

FIG. PAGE. 

470. Uterus Opened, Showing Multiple Interstitial Myomata, 660 

471. Sectioned Surface of Uterus Showing Several Fibroid Tumors, 661 

472. Serous Surface of Same Specimen, 661 

473. Uterus Incised Containing Interstitial Fibro-myomata, 662 

474. Uterus Incised Showing General Circumscribed Fibro-myomata, 663 

475. Subserous Myomata, 664 

476. Pedunculated Myoma of the Cervix, 665 

477. Sessile Myoma of the Cervix, 666 

478. Bicornate Uterus. Both Cornua Containing Myomata, 670 

479. Intraligamentary Myoma, 673 

480. Large Desmoid Tumor of Abdominal Wall Weighing Upon Removal 

19J Pounds, 677 

481. Histologic Section of Desmoid Tumor, 678 

482. Myoma Uteri with Large Intraligamentary Fibromata, 681 

483. Fibrocystic Tumor of the Uterus (Auvard), 683 

484. Submucous Fibromyoma Undergoing Cystic Change, 684 

485. Myoma of the Body and Cancer of the Cervix, 685 

486. Uterus Incised Displaying Numerous Fibro-myomatous Growths and 

Incipient Cancer of the Cervix, 686 

487. Myoma Uteri Complicated by Pyosalpinx, 688 

488. Uterus Containing Several Fibroid Tumors Complicated by a Large 

Tubo-ovarian Cyst, 688 

489. A Myoma Which, from the Associated Ascites, Had Been Mistaken 

for Pregnancy, 689 

490. Tumor Shown after Removal, 690 

491. Myoma Complicated by Pregnancy, 691 

492. Uterus Containing Large Fibroid Tumor and Three Months' Fetus, . . 692 

493. Incision of Cervix to Expose Intra-uterine Myoma, 706 

494. Cervix and Capsule Incised, the Latter Pushed Back, 707 

495. Removal of Myoma by Torsion of Its Pedicle, 709 

496. Incision of Pedicle of Myoma, 710 

497. Enucleation of Tumor through the Vagina, 711 

498. Interstitial Tumor Exposed by Vertical Incision of the Anterior Lip,. 712 

499. Myoma of Anterior Wall Exposed by Transverse and Vertical Incision, 713 

500. Myoma of Posterior Wall Exposed by Retro-uterine Incision, 714 

501. Removal of Myoma by Morcellement, 715 

502. Abdominal Myomectomy (Dudley), 721 

503. Abdominal Enulceation of Myomata and Method of Closing the 

Uterine Wound (Dudley), 721 

504. Supravaginal Removal of Myomatous Uterus (Kelly), 725 

505. Cervix Cut Across Preliminary to the Complete Ligation of One 

Ligament (Kelly, modified) , 726 

506. Stump Covered with Peritoneum, 727 

507. Panhysterectomy. Doyen's Method, 731 

508. Cervix Separated from the Vagina, and Being Pulled away from the 

Bladder and Ureters, 732 

509. Mucous Polypi, 743 

510. Squamous-cell Carcinoma of the Cervix, 746 

511. Squamous-cell Epithelioma of the Uterus, 754 

512. Adenocarcinoma of the Cervical Canal, 755 

513. Adenocarcinoma of Body of the Uterus, 756 

514. Cauliflower Growth Involving the Vaginal Part (Winter), 757 

515. Cancerous Ulceration of Intracervical Canal (Ativard), 758 

516. Cervical Wall Infiltrated while the Vaginal Portion is Largely De- 

stroyed (Veit), 759 

517. Circumscribed Cancer of Body of Uterus (Ativard), 760 

518. Diffuse Cancer of Uterine Body, 761 

519. Adenocarcinoma of Uterine Body, 761 

520. Incipient Adenocarcinoma of Uterine Mucous Membrane, 762 

521. Entire Cavity Covered with Nodular Growths 762 

522. Communication between Bladder, Vagina, and Rectum (Auvard),. ... 763 

523. Cervical Canal Destroyed by Progress of Disease, 764 



LIST OF ILLUSTRATIONS. XXXVll 

FIG. PAGE. 

524. Uterus Removed from an Unmarried Woman Twenty-two Years of 

Age, 771 

525. Formation of Flap to Cover Diseased Surface Preliminary to Opera- 

tion, 789 

526. Ligation of the Anterior Trunk of the Internal Iliac, 803 

527. Skin Incision for Sacral Resection, 807 

528. Sacrum Resected; Rectum Exposed, 808 

529. Rectum Pushed Aside; Uterus Exposed, 809 

530. Patient from Whom Uterus, Ovaries, Posterior Wall of Vagina, 

Perineum, and Five Inches of the Rectum Have Been Removed, 812 

531. Chorio-epithelioma of the Uterus, 832 

532. Chorio-epitheHoma Malignum {Noble and Tracy), 833 

533. Histologic Section of Chorio-epithelioma, 833 

534. Endothelioma of the Uterus, 835 

535. Sarcoma of the Body of the Uterus, 837 

536. Fibroma Undergoing Sarcomatous Change {Auvard), 847 

537. Papilloma of the Fallopian Tube {Doleris), 854 

538. Broad Ligament Cyst {Sutton), 856 

539. Broad Ligament Cyst, with Torsion of Its Pedicle, 857 

540. Large Ovarian Tumor, 860 

541. Small Residual Cysts {Dudley), 861 

542. Cyst of the Corpus Luteum, 862 

543. Tubo-ovarian Cysts, 863 

544. Large Ovarian Cyst. Patient Upright, 864 

545. Ovarian Cyst. Patient Recumbent, 865 

546. Pedicle of an Ovarian Cyst {Doran), 865 

547. Intraligamentary Ovarian Cyst, 866 

548. Cyst Embedded in the Pelvis, 867 

549. Adenocystoma of Ovary, Showing Papillary Formation, 868 

550. Areolar Ovarian Cyst, 869 

551. Unilocular Ovarian Cyst {Winter), 870 

552. Multilocular Cyst {Doran), 871 

553. Small Papillary Ovarian Cyst, 872 

554. Papillary Tufts upon Inner Wall of Cyst {Doran), 872 

555. Surfaces of Ovaries Infected with Papillary Vegetations {Doran), .... 873 

556. Papillary Ovarian Cyst, 874 

557. Dermoid Ovarian Cyst, 875 

558. Fibromyoma of Ovary {Veit), 876 

559. Sarcoma of the Ovary {Veit), 876 

560. Torsion of the Pedicle, 882 

561. Dermoid Which Had Lost Its Original Relations and Was Nourished 

by Adhesions from the Omentum, 884 

562. An Ovarian Cyst beneath a Pregnant Uterus, 886 

563. Desmoid Tumor of Abdominal Wall, 889 

564. Relative Zones of Dullness and Resonance in Ascites, 891 

565. Relative Zones of Dullness and Resonance in Ovarian Cyst, 892 

566. Hegar's Method of Determining Relation of Tumor to the Uterus 

(Winter), 894 

567. Cyst Forceps, 906 

568. Wall Incised; Cyst Exposed, 907 

569. Cyst Punctured and Being Withdrawn, 908 

570. Withdrawal of Sac, Showing Adhesions, 909 

571. Ligatures Introduced through Broad Pedicle, 910 

572. Interlacing of Sutures to Prevent Splitting of Pedicle, 910 

573. Sutures Interlaced and Tied, 912 

574. Splitting of Pedicle when Sutures are Tied without Interlacing, 915 



A 

Text-book of Gynecology. 



INTRODUCTION. 

1. Definition and Antiquity. — Gynecology comprises the study 
of the diseases peculiar to women. The description of the sotuid 
and various forms of specula, specimens of which have been 
found in the ruins of Pompeii and Herculaneum, and directions 
given in manuscripts for the treatment of special conditions, 
make it evident that the ancients possessed some knowledge 
of the disorders of the female genital tract, but it can not be 
disputed that the greatest progress in the development of the 
science occurred during the last half of the nineteenth century. 

2. Theories. — The study of the progress of the science is 
not without interest and profit, and in its development we wit- 
ness the pendulum swing from one extreme to another. The 
origin of disease is based upon local inflammation by one; by 
another it is ascribed to constitutional conditions of which the 
local condition is only an expression. The cervix has been 
considered the offending portion of the tract, and its inflammation 
the cause of every trouble. The ovaries have been accused of 
dominating the other organs, and producing in them secondary 
or reflex phenomena. Displacements of the uterus, particularly 
the flexions, have been, and still are, asserted to be the main 
source of the disorders of the pelvis. The tubes have been 
indicated as the instigators of the function of menstruation, 
and consequently to pathologic lesions of these organs are at- 
tributed the majority of abnormal conditions of the genital tract. 

3. Foundation. — An analysis of the different theories discloses 
that the truth is contained, not in one but in a proper com- 
bination of all. The influence of one organ upon another due 
to the arrangement of vascular and nerve supply is signiflcant, 
and a proper appreciation of the subject is reached only after- a 
very careful study and analysis of all the phenomena presented. 

4. Purpose. — It should not, upon the one hand, be considered 
the true province of the student of gynecology to ascertain that a 
patient has a uterus which should be subjected to the routine use 

1 1 



Z GYNECOLOGY. 

of Speculum, sound, and applicator; nor, upon the other, that the 
recognition of the existence of ovaries and tubes justifies the con- 
clusion that every symptom of distress or discomfort from which 
the patient complains must indicate in them a pathologic lesion 
which will of necessity justify their sacrifice. The gynecologist 
should be one who will be assiduous in the study of the history 
of disease; ready to discern its cause; careful in eliciting the 
subjective symptoms, and proficient in determining physical 
signs, who will exercise correct judgment in comparing and 
analyzing the knowledge thus secured, and has such in- 
tegrity that the patient may feel assured she will not be treated 
for diseased conditions which are not present. 

He must be so conservative that he will sacrifice no organ 
whose physiologic integrity is capable of being restored ; so bold 
and courageous that his patient shall not forfeit her opportunity 
for life or restored health through his failure to assume the respon- 
sibility of any operative procedure necessary to secure the object. 



ETIOLOGY. 

5. Importance of Etiology. — A knowledge of the causes 
which result in the production of disorders of the genital tract 
are essential to the ready recognition of their character and to 
the employment of proper measures for the relief of the suffer- 
ing victim. The study of the forces which combine for the 
production of genital disorders are especially complex, for they 
comprise not only the actions of the diseased, but also of those 
with whom she is associated and those who have been her pro- 
genitors. Here, truly, we see the sins of the parent visited upon 
the children not only to the third, but to many generations. 

6. Classification. — The causes of disease are difficult to clas- 
sify, and are sometimes divided into two great classes, the pre- 
disposing and exciting. When considering some particular 
class of disease, as, for instance, inflammation, such classification 
can readily be arranged, but when we come to consider all the 
disorders to which the genital organs are subject, it becomes 
more difficult to assert what are predisposing and what are ex- 
citing. In one individual the diseased state can be directly 
traced to abnormalities in development; in another to defects 
in her manner of life; a third may have had disease brought 
to her through her sexual life, and a fourth sufter from injuries 
incident to reproduction. 

The following seems sufficiently comprehensive : 

(a) Hereditary and congenital. 

(b) Hygienic. 



ETIOLOGY. 6 

(c) Sexual. 

(d) Traumatic. 

(e) Infective. 

(/) Causes incident to age. 

7. (a) Hereditary and Congenital Causes. — It seems impos- 
sible, yet is demonstrated day by day that the atoms supplied 
by the male and female which unite to set up processes of con- 
struction for a new life contain within their minute compass the 
impetus which is to lead to the development of traits and char- 
acteristics similar to those possessed by their progenitors. 

These traits and characteristics involve not only shade, 
form, and color, but mental and moral attributes. Imperfections 
and unfortunate traits which are common to the parents are 
intensified in the offspring. A knoAvledge of such transmission 
is employed by the stock raiser to improve his herds. Only 
such males are employed as will improve and correct the rec- 
ognized defects of his herd. While it is impossible to introduce 
in the relation of the sexes of the human race the precision of 
the stock breeder, it cannot be denied that the production of 
healthy offspring is too rarely the motive for such union. Family, 
position, and wealth are more frequently considered essential 
than are good health and good morals upon the part of the elected 
husband. The worn out roue, the debauched or decrepit son 
of wealth are preferred to the virile young man who has his 
fortune to make. A feeble or sexually exhausted male united 
to a cold, dispassionate woman with no, or but little, inclination 
to maternity must result in the production of offspring with 
still lower sexual virility. Sterility, defective sexual and phy- 
sical development, and lessened powers of resistance are likely 
to characterize the offspring of such a union. Intemperance 
in eating and drinking, overwork, exhaustion from indulgence 
in the exigencies of fashionable life, and a tendency to marked 
fat production in one or both parents, lessens virility and vitality 
in the children. Intensification of pre-existing traits, the oc- 
currence of vicious tendencies, lessened resistance to certain 
constitutional diseases as tuberculosis, the gouty diathesis, and 
malignant degenerations may be transmitted from parent to 
child and are known as hereditary causes of disease. Not infre- 
quently from careful hygiene, improved environment, and other 
favorable conditions such tendencies may not make their ap- 
pearance in one or more generations and apparently become 
intensified in one less favorably situated. The most marked 
influence upon the sexual life of the individual will be rec- 
ognized in the study of the development of the ovum. During 
,its progress of development the ovum is subjected to vari- 
ous disorders which may lead to arrest or deranged formation 



4 GYNECOLOGY. 

of the structures of the genital tract, dependent, of course, 
upon the period or stage of development in which this may 
take place. Should the change occur before the separation of 
the Miillerian ducts and the genital bodies from the Wolffian, 
there may be an absence of the structure upon the side affected, 
so that kidney, ovary, tube, and one horn of the uterus are want- 
ing. In the later stages of development one or both Miillerian 
ducts may be affected, resulting in absent, rudimentary or 
defective uteri. The ducts may fail to coalesce or form ap- 
parently well developed uteri and vagina, with a septum between ; 
or the coalescence may be partial. Failure to coalesce causes 
the development of separate and generally rudimentary uteri 
and vagina. Partial coalescence may involve only the vaginal 
portion of the tubes, with the two horns of the uterus com- 
pletely separated, making a double uterus, or it may be a bi- 
comate uterus joined together with a common neck; or the 
division may be in the fundus of the uterus only. In the devel- 
opment of the tubes, the inflammatory process which results 
in the arrest of development may affect one tube only, while 
the other goes on to full development. The rudimentary duct 
may encircle to some degree the well developed organ. Such 
a condition may result in the development of a uterus which 
is unequal to the proper performance of its functions and en- 
danger the life of the woman in a subsequent gestation, or the 
horn may be so well developed as to carry on its functions with- 
out the abnormality being suspected until some operative pro- 
cedure discloses, the actual condition. The rudimentary horn 
may in some cases be associated with an atresia of the corre- 
sponding vagina. Such a condition would not attract attention 
until subsequent to puberty, when fluid unable to escape would 
accumulate in the defective tube, forming a more or less defi- 
nite tumor. Such a tumor may be situated to one side of the 
vagina, but more frequently pointing somewhat anterior to the 
well formed canal. In a patient coming under my observation 
the woman had given birth to two children and was at that time 
a victim of a large interstitial fibroid growth in the uterus. 
Examination revealed a pouch to the anterior and right of the 
vagina, the character of which was not recognized until during 
the operation, when it was found that it was the blind pouch of 
a rudimentary uterus. The septa dividing the vagina pro- 
duced no appreciable influence and are unlikely to be discovered 
until after the marriage of the individual. The septum pro- 
duces so small a tube as to lead to discomfort and pain during 
the marital relations and to obstruction during parturition. 
The amount of obstruction, of course, in the latter will depend 
upon the thickness and firmness of the septum. Generally it 



ETIOLOGY. . O 

is torn through the greater part of its extent during parturi- 
tion. Occasionally, subsequent to parturition, a bridle or 
remnant of this septum will be found connecting the anterior 
and posterior wall of the vagina, the remaining portion of it 
having either been torn through or sloughed away as a result 
of parturition. The defective development may involve the 
lower part of the genital tube, affecting the vagina and vulva. 
Thus, there may be an absence of the urethra, a condition of 
hypospadias, in which the urethra opens into the vagina. The 
portion of the vagina may have undergone atresia or the vulvar 
orifice of the vagina may be closed by an imperforate hymen. 
These conditions are not likely to produce symptoms until the 
woman has reached and passed the period of puberty, when 
the occurrence of the menstrual moHmina without the pres- 
ence of a discharge indicates something abnormal. If the con- 
dition is not recognized a tumor will ultimately develop as a 
result of the retention of the menstrual discharge. The de- 
formities may affect the labia majora, the labia minora, the 
former being thin, a slight amotmt of fatty tissue, or the inguinal 
canal may remain open, permitting the secretion from the 
peritoneal cavity to descend into the sac, forming a hydrocele, 
or the intestine pushed down, causing hernia. The labia minora 
may be elongated or may be almost absent. The clitoris may 
be defective in its development or be so large and hypertro- 
phied as to lead to doubt as to the sex. This malformation may 
affect the genital organs of either sex, giving rise to uncertainty 
as to the sex of the individual under consideration, when it is 
known as hermaphroditism. True hermaphroditism, the presence 
of both organs in the same individual, probably does not exist. 
Pseudohermaphroditism, or a condition in which the organs 
of one resemble the other sex, are quite frequent. IMalforma- 
tions of this character, Avhich have occurred during the progress 
of the development of the ovum, are known as congenital con- 
ditions in contradistinction to those Ave have been considering 
as hereditary. 

8. (b) Hygienic Causes. — Woman is hke a flower. To reach 
the highest development she must generously absorb the rays 
of the sun and drink deeply of pure air. Unfortunately, the 
tendencies of civilization have been to deprive her of these 
essentials at the period of life when she is in most need as she 
enters into womanhood. Her male companions, with whom 
until this time she has enjoyed almost equal freedom, are still 
permitted to enjoy the freedom of Nature, while she is con- 
demned to interest herself with indoor pursuits. No longer 
allowed to romp and play she is doomed to practice being a 
lady. Stiffly and often tightly dressed, she is compelled to 



6 GYNECOLOGY. 

assume the attitude and thoughts of a mature woman, and 
what exercise she secures is taken so sedately as to be unworthy 
of that designation. At the period of hfe when the development 
of her sexual functions are making the greatest draft upon her 
nervous system, she is confined closely to her books and music, 
securing the accomplishments and embellishments which are 
to be her capital. At an early age she is introduced to society, 
and if fortunately (?) situated her life becomes a continuous 
whirl of parties and entertainments entailing late hours, irregu- 
lar meals, undue exposure, excitement, and a continual appeal 
to the emotions. Her social position demands that the natural 
contour of the body be distorted by tight dresses, which dis- 
place the viscera from their normal relations, increasing intra- 
abdominal pressure, and driving the pelvic organs to a lower 
level. The circulation in these organs is necessarily influenced 
by the interference with the venous return, thus causing stasis. 
The compression of the lower part of the chest interferes with 
the expansion of the lungs, with the action of the stomach, 
heart, and liver, so that the processes of nutrition are affected, 
and the individual suffers from anemia, neurasthenia, defective 
action of the digestive tract, and disturbances of the functions 
of the genital organs. The faults enumerated are still further 
enhanced by enveloping the central portion of the body with 
skirts supported from the waist, while the extremities are clad 
in network hose and thin shoes or slippers, and the neck, chest, 
and arms bare. She ordinarily will go fairly clad and make 
the above changes in the coldest weather; occupying crowded 
rooms, subject to drafts, and this regardless of the menstrual 
periods. Should it be surprising that serious pelvic disorders 
are frequent? That pelvic disease is the rule rather than the 
exception? The usual life of the young woman precludes regu- 
larity in the performance of her functions. The evacuation of 
her bowels and bladder are neglected. Retention of the con- 
tents of these viscera produce repeated displacements of the 
uterus which finally become permanent ; the failure to evacu- 
ate the bowels causes a toxemia which profoundly influences 
nutrition and produces toxic symptoms, in which the pelvic 
organs have a considerable part. 

Want of general cleanliness necessarily has a marked influ- 
ence upon the health and nutrition of the individual. The 
skin takes a very active part in the processes of elimination 
and must be kept in good condition by proper and systematic 
bathing to do effective work. Neglect of local cleanliness re- 
sults in the decomposition of the accumulating secretions from 
the vaginal tract, and the sweat and sebaceous glands of the 
vulva, which are to some degree soiled with urine. Such an 



ETIOLOGY. / 

accumulation forms an excellent culture fluid for micro-organisms 
and diseases of the vulva and vagina are thus produced. The 
retention of the smegma beneath the prepuce of the clitoris 
leads to irritation and adhesions between it and the glans, to 
irritation of the bladder, frequent micturition, wetting of the 
bed, to nervous disorders, sometimes convulsions, and frequently 
to masturbation. 

9. (c) Sexual Causes. — With the development of puberty 
the sexual instinct dominates the female organism. Her view- 
point of life changes. However exalted her ambition to attain 
eminence in some unusual line the impetus to maternity cannot 
be extinguished. Less passionate, less lustful than man, she 
yet clings with greater constancy and devotion to the companion 
of her choice. Her more limited- sphere of action in life; her 
more delicately organized nervous system, renders her especially 
susceptible to the influence of the emotions. While the sexual 
desire or eroticism varies in individuals, the majority of women 
yield to the sexual relation through a desire to please the man 
rather than from any sexual inclination, from a desire to gratify 
rather than to be gratified. Many women experience no sense 
of pleasure during or as a result of the sexual act, and regard 
it as only a means to an end, viz., the retention of the affections 
of her companion and the production of offspring. Some women 
experience so much physical discomfort during the act and such 
a degree of nervous irritation following it as to cause them to 
regard the approach of the male with absolute disgust and re- 
pugnance. The life of a woman of the latter class with an 
erotic man — a man who is so selfish as to care only for his own 
gratification — ^becomes a "hell on earth." She considers herself 
a sexual slave, bound to a man whose only regard for her is as 
an instrument to minister to his passion. Whatever regard 
she formerly entertained for him soon becomes dissipated. 
Constant dwelling upon her sense of wTong and fretting against 
the bonds which envelop her, leads not only to the production 
of local disorder but to melancholia, hysteria, neurasthenia, 
and even mental derangement. 

Stimulation of eroticism by bad literature, by intimate 
association with the opposite sex, or by onanism, are prolific 
in the development of local disease. Long engagements, unless 
occasioned by separation, are prejudicial in that the frequent 
hyperemia produced by repeatedly awakened and unsatisfied 
longings causes chronic oophoritis. 

Equally disastrous is the union of a young erotic woman 
with an old and especially impotent man. 

The most potent factor to-day in the production of pelvic 
disease is consequent upon efforts to avoid maternity. Nature 



8 GYNECOLOGY. 

has her revenge upon those who would violate her laws. 
When the natural result of the marital relation is avoided by 
withdrawal of the penis before the act is completed both parties 
to the act are injured. The incomplete discharge causes the man 
an irritation which produces a sensation of discomfort and unrest 
that leads to more frequent coition and consequent nervous 
exhaustion, or neurasthenia for both participants. The con- 
tinuous engorgement without the salutary influence of the com- 
pleted orgasm and the failure of impregnation produces a con- 
tinued hyperemia which renders the soil favorable for the de- 
velopment of the various pelvic inflammations. The deliberate 
indulgence of the sexual appetite with the premeditated inten- 
tion of avoiding its legitimate result, begets a lowered moral 
attitude toward the sexual relation. The w^oman who con- 
tinually avoids the possibility and responsibility of maternity 
becomes little more than her husband's mistress, indeed, it may 
often be questioned whether she is regarded so highly. If 
her sexual appetite be strong and she resents the apparent 
neglect of her husband, it does not become a long step for her 
to become the mistress of another. A woman so lost to the 
purpose of the marital relation will not hesitate to employ, or 
have employed, agents for the arrest of pregnancy when it occurs 
in spite of the precautions observed. Abortions or repeated 
abortions necessarily induce disorders of the pelvic or- 
gans. Nature makes her provision for the evacuation of the 
uterine contents when the fruit has matured and earlier separa- 
tion finds it unprepared to easily resume normal relations. 
Involution is less rapid and prone to be incomplete. Subin- 
volution, descent, displacements, chronic endometritis and 
metritis, periuterine inflammation, and tubal and ovarian disease 
are consequences of such interference. The genital organs may 
become so crippled as to render subsequent conception impossi- 
ble, or so irritated as to render the uterus unable to supply the 
necessary nutrition to mature the implanted ovum and abortion 
becomes the habit. 

10. (d) Traumatic Causes. — The injuries to which the genital 
tract are subject may be accidental, the result of violent efforts 
at intercourse, consequent to parturition, or the result of opera- 
tive procedures. The accidental injuries are comparatively 
infrequent, and, while capable of producing cicatricial changes, 
are generally insignificant in their ultimate effects. Coition 
has produced laceration of the perineum, tearing off of a rigid 
and resisting hymen, tearing of the vagina, and the formation 
of rectovaginal fistula. The act of coition is most likely to 
produce severe injury in the very young or in the elderly virgin. 
The greater majority of injuries occur from lesions of parturi- 
tion. These may involve the body of the uterus, the cervix, 



ETIOLOGY. y 

the vagina, perineum, or pelvic floor, and the adjacent viscera. 
The lesion may be in the nature of a tear with healthy tissue 
which if kept free from infection soon heals, leaving only a more 
or less well marked cicatricial band, or as a result of long con- 
tinued pressure or bruising, is followed by extensive sloughing 
and loss of tissue, which, if recovery occurs, must be attended 
by deformity. Lesions of the genital canal are favored by 
malformations of the bony and soft part of the pelvis; small 
and contracted genital canal, undersize or malposition of the 
fetus, rigid and unyielding muscular structure, an inordinate 
amount of fat in the maternal tissues. Enfeebled muscular 
action and ineffective labor pains by which the tissues are sub- 
jected to long continued pressure between the bones of the 
fetal head and those of the pelvis, and the rash and unskilful 
employment of manual and instrumental manipulation. The 
prompt and skilful resort to assistance has greatly lessened 
the frequency of seyere lesions. It is true lacerations of the 
cervix and pelvic floor may be relatively more frequent under 
early interference, but such lesions are easily repaired and pro- 
duce far less serious consequences than the extensive destruc- 
tion of tissue resulting from protracted labor 

Any lesion of the pelvic floor becomes an avenue for the 
entrance of infection. Extensive lacerations of the cervix and 
pelvic floor interfere with the process of involution so that the 
organs are much longer in reaching the normal, which may be 
prevented by various sequels. In laceration of the cervix, 
in addition to subinvolution, the cervical lips are frequently 
separated, the posterior may undergo involution while the an- 
terior becomes hypertrophied. Increased secretion occurs from 
the cervical glands or superficial inflammation may lead to 
stenosis of the gland ducts and distention of the Nabothian 
glands until the entire cervix has undergone cystic degeneration. 
In some cases the torn surfaces may become cicatrized, fllling 
up the angles of the tear with wedges of cicatricial tissue, in 
which the nerve tendrils are imprisoned and pinched, produc- 
ing various reflex phenomena. Occasionally the pressure of 
the cervix against the posterior wall of the vagina will lead to 
turning of the lips, the posterior upward and the anterior down- 
ward, in which position they are held by indurated tissue within 
the injured surfaces. The resulting endocervicitis, thickened 
mucosa, and distended glands produce ectropion of the mucosa, 
which increases the separation of the lips. 

That this condition is an incentive to the occurrence of 
carcinoma of the cervix is made evident by the fact that this 
is most frequently found in the cervix and in the cervices of 
women w^ho have given birth to one or more children. Lacera- 



10 GYNECOLOGY. 

tion of the pelvic floor in slight degree lessens the support of 
the viscera and retards involution, and the combination of de- 
creased support and increased weight of the superimposed 
viscera promotes descent, displacement, and chronic inflamma- 
tion. Laceration through the sphincter leaves the intra-ab- 
dominal pressure unantagonized and renders the patient unable 
to control the contents of the lower bowel. The enforced de- 
privation of society by this condition not infrequently results 
in melancholia and mental disturbance. Fistulous openings 
between the genital canal and the adjacent viscera produce con- 
stant soiling of her person with urine or feces, irritating the 
skin of the vulva and of the thighs, and make her a source of 
distress to herself and her friends. 

The discussion of the traumatic causes of pelvic disorder 
is incomplete if some consideration is not given to those which 
result from operative procedure. They are mostly the result 
of want of skill, improper technique, inexperience, and faulty 
judgment. No man should undertake pelvic surgery who has 
not had large opportunity for observation in diagnosis, and a 
careful training in surgical technique. Every surgeon is sad- 
dened by seeing patients who had not been seriously ill prior 
to a cureting, with conditions demanding sacrificial operations, 
women bemoaning the loss of ovaries, who from the history evi- 
dently did not require such a sacrifice. Patients with fistulae, 
hernia, adhesions, intestinal constrictions, living lives of misery 
and discomfort, who could have been readily restored to health 
had their operators been better trained. 

II. (e) Infective Causes.— Inflammatory diseases of the 
pelvis are with extremely rare exceptions the result of the pres- 
ence of micro-organisms. Those which are the most frequent 
in their baleful influence are the gonococcus, the staphylococcus, 
pyogenes aureus, the streptococcus, the bacillus coli communis, 
and the bacillus tuberculosis. The retention of portions . of 
tissue which are exposed to the atmospheric air through the 
introduction of the saprophites cause putrefaction and through 
the absorption of the resulting toxins develop high tempera- 
ture. The condition is denominated sapremia as contradis- 
tinguished from the multiplication of septic germs which pro- 
duces septicemia. 

The gonococcus is without question the most prolific source 
of infection and invades the vulvo- vaginal glands, the vagina, 
cervix, body of the uterus, the tubes, the ovaries, and the pelvic 
peritoneum. Its occurrence in a severe degree makes uncer- 
tain its subsequent cure. Certainly no case is cured in the sense 
of restoration to normal relations, nor can we be certain that 
the subsequent symptoms will be in the form of sequelae, for 



ETIOLOGY. - 11 

numerous cases occur demonstrating recurrence of the disease 
without opportunity for fresh infection. Such attacks burst 
forth, following sexual excess, intemperance in eating or drink- 
ing or after exposure. Experiences of this character have been 
manifested when previous examinations of its secretions have 
demonstrated that the gonococcus was absent. Recent re- 
searches have seemed to demonstrate that the gonococci lapse 
into forms indistinguishable from pus cells or leukocytes and 
return to their characteristic form when galvanized into activity 
by some irritation. Such an explanation accounts for the re- 
infection in the previous A'ictim and its transmission by him 
to others. 

The gonococcus renders the soil by it infected more favorable 
for the reception and nutrition of other micro-organisms. The 
simultaneous action of some other organism w4th the gono- 
coccus is known as a mixed infection. The retention of decom- 
posing products and the occurrence of sapremia is also favorable 
for the development of the graver forms resulting in sepsis. 

Infection from the staphylococcus, or streptococcus, is always 
grave. Its progress depends upon the virulence of the infec- 
tion and the vital resistance of the patient. It may become 
promptly localized or rapidly infect the blood and ultimately 
result in death. The bacillus coli communis is most likely to 
expend its baneful influence upon the peritoneum of the ad- 
jacent structures. The tubercle bacillus may affect any portion 
of the genito -urinary tract. Next to the lungs it probably 
most frequently invades the peritoneum. 

12. (f) Causes Incident to Age. — The most superficial obser- 
vation reveals that the age of the woman renders her more sus- 
ceptible to certain forms of disease. Some disorders are prone 
to occur at certain ages. 

The period prior to the manifestation of puberty is especially 
free from disorder. This is a period of quiescence. Even dur- 
ing this period we find the individual suifering from gonorrheal 
infection, producing vulvo-vaginitis, a condition requiring 
prompt treatment to prevent its extension to the uterus and, 
indeed, to the appendages, causing irrecoverable alterations. 
Ovarian growths occasionally manifest themselves during this 
period. A¥ith the advent of puberty the disorders multiply. 
Malformations render their existence recognizable in retention 
of menstruation, from atresia, vagina or uterus, or imper- 
forate hymen. A poorly developed uterus may be unable to 
readily perform its functions, so the patient suffers from dysmen- 
orrhea and sterility. During the years of active menstrual 
life, the chaste unmarried woman sufters from endom.etritis, 
oophoritis, the occurrence of mvomata, and chronic inflamma- 



12 GYNECOLOGY. 

tion of the ovary. Ovarian tumor and occasionally carcinoma 
may be manifested. The latter in the virgin is most likely to 
affect the body. 

The married woman, while possibly slightly less susceptible 
to myomata, suffers from infection, producing endometritis, 
metritis, salpingitis, oophoritis, and periuterine inflammation, 
either perimetritis or parametritis, or the two combined. She 
is more prone to cervical carcinoma from the injuries the cervix 
receives during parturition. Infections are much more prone 
to be found in such patients from their greater exposure in the 
contingencies incident to the sexual relations, the possible inter- 
ruption in the course of pregnancy, and the increased exposure 
at the period of parturition. 

Carcinoma, while possible at any period, is more prone to 
manifest itself at or near the menopause, ovarian cystomata 
are more frequent during this period, but may occasionally 
develop before or after the period of menstrual life. Subse- 
quent to the menopause carcinomata, prolapsus, and senile en- 
dometritis are the affections most frequently seen. 

13. Difficulties in Study. — The discussion of etiology has 
demonstrated the difficulties in the study of gynecology, but 
will be found no less marked where the student essays a correct 
diagnosis. Probably no department of medicine interposes 
greater barriers to its accomplishment. In the study of the dis- 
eases of women much must depend upon proficiency of touch, 
which is acquired only b}^ extensive practice. The delicacy 
and proficiency of this sense varies so greatly in different indi- 
viduals that it is difficult to convey an adequate idea of the 
relative hardness or softness of the structures under observa- 
tion. 

The ovaries and tubes in which important lesions occur 
are in many patients quite inaccessible to the ordinary methods 
of examination. Pathologic lesions must often, then, be the sub- 
ject of inference or speculation, rather than capable of absolute 
demonstration. To render the study of symptoms more difficult, 
the suggestion that she must subject herself to examination is 
repugnant to the modesty of every woman, and the disease ex- 
ists in organs so sensitive that manipulation can not be repeated 
by a number of persons in succession. The patients who are 
willing to be brought before a class of students and subjected 
to such examination are exceedingly few, consequently many 
practitioners must enter upon their vocation with but little or 
no practical knowledge of the subject. 

14. Observation. — The cultivation of habits of close observa- 
tion is of the utmost importance. The observing physician will 
generally be able to determine with considerable accuracy the cir- 



ETIOLOGY. . 13 

cumstances, condition, and diseased state of the patient from her 
conduct, manner, and general appearance. Thus, a woman with 
an abdominal enlargement who enters a physician's office with a 
face presenting the rosy hue of health, and appears well nourished, 
would naturally be suspected of suffering from a physiologic rather 
than a diseased condition, and would be pronounced pregnant; 
while such an enlargement associated with a pale countenance, 
an emaciated face, thin cheeks, and sunken eyes would be re- 
garded as indicating an ovarian growth. This special association 
of the features is known as fades ovariana, and is of value in 
forming the diagnosis. The conduct and deportment of the 
patient will frequently announce whether she is married or 
single ; her manner of walking or sitting, the existence of a pelvic 
inflammation. 

15. Exercise of Judgment. — Errors in diagnosis are most fre- 
quently the result of hasty conclusions founded upon insufficient 
investigation. The recognition of the existence of some lesion 
is at once accepted as an explanation for all the distressing 
symptoms. The accurate diagnostician will not come to a con- 
clusion until a careful and thorough examination of every organ 
capable of producing such symptoms has been made. 

16. Value of Notes. — The young physician should accustom 
himself to taking notes of his office cases ; he thus forms the habit 
of more careful and systematic investigation of every patient, 
accumulates data from which he is enabled to formulate more 
definitely judicious plans of treatment, and, probably most im- 
portant of all, has the means of refreshing his mind from time to 
time as to the condition of any particular patient. 

17. History. — The notes should record the name, residence, 
age, condition of patient, married or single, family history, per- 
sonal history (as previous sickness, duration of present illness, 
supposed cause, progress, and symptoms). 

Menses: first appearance, regularity, duration, what changes 
have since occurred; present habit, date of last menstruation. 

Pain, whether it precedes, accompanies, or follows the periods, 
its character, severity, and where experienced. 

Leiikorrhea: amount of discharge, duration, continuance, 
color, consistence, and effect upon the parts with which it comes 
in contact. 

Number of children or miscarriages:' character of labor and 
convalescence and the influence upon subsequent health. 

Coition: painful, sensation, frequency, methods employed to 
avoid conception. 

Interrogation of other organs: regularity of alvine dejections, 
frequency of micturition, digestion; pain in head, in lumbar 
region, in groins, doAvn the limbs, etc. 



14 GYNECOLOGY. 

The inquiry need not, possibly should not, in all cases pursue 
the order here laid down. In some instances it will be better to 
permit the patient to tell her own story ; in others it will be neces- 
sary to guide her course by an occasional judicious question, or 
to assume the position of questioner, and patiently endeavor to 
secure a complete history. While the appearance and the char- 
acter of the symptoms may indicate a certain interpretation, the 
physician should reserve his judgment as to the condition until 
the testimony of subjective and objective symptoms has been 
completely secured, and then arrive at the diagnosis after their 
careful analysis. 



DIAGNOSIS. 

i8. Subjective Symptoms. — The subjective symptoms are 
those which are elicited from the patient or her attendants. As 
already asserted, the difficulty experienced in determining the 
physical signs frequently make these symptoms of great value. 
Every such symptom, however, must be carefully weighed, as 
both patient and attendants are prone to exaggerate the charac- 
ter and severity of symptoms or may err in observation and 
in interpretation. 

19. Causes of Error. — Lisfranc* writes: "By their almost 
latent state, their great variety of symptoms (often very transi- 
tory), their sympathetic effects on all parts of the economy, and 
their immense influence on the nervous system, uterine diseases 
are peculiarly apt to lead medical practitioners into errors of 
diagnosis." 

The reason for these errors is the difficulty in understanding 
their cause. The uterine symptoms are not always the most 
prominent, are slowly developed, and do not always attract the 
attention of the patient. Not infrequently is the physician con- 
sulted for disorder of the stomach, of the heart, or of the liver; 
for vomiting, nausea, want of appetite, or diarrhea; for neuralgia 
or hysteria ; for a train of evils having their origin in poverty of 
the blood, as chlorosis, anemia, emaciation, and exhaustion — all 
of which may be symptomatic manifestations of an obscure 
uterine malady. 

20. Method of Procedure. — The examiner should proceed 
from general to local symptoms so systematically as to bring 
the patient to the conviction upon the completion of the exami- 
nation that the only logical outcome is a physical investigation 
of her pelvic organs. 

*" Cliliique Chirurgicale de la Pitie," vol. 11, p. 182, Paris, 1842. 



DIAGNOSIS. 15 

21. General Symptoms. — In many women the general or 
constitutional symptoms are so predominant, as to wholly ob- 
scure the diagnosis and cause both patient and physician to 
believe that organs other than those of the pelvis are directly 
at fault. The symptoms of which complaint will be most fre- 
quently made are gastric, such as gastralgia, nausea, vomiting, 
perverted appetite, anorexia, and regurgitation associated with 
a clean tongue. Nausea and obstinate vomiting are likely to 
be associated with ovarian disease. Intestinal indigestion, 
indicated by gaseous distention, the formation and absorption 
of toxins, produces disturbed sleep, unpleasant dreams, perver- 
ted nutrition, and neurasthenia. Nervous anesthesia affects 
portions of the lower extremities, as over the front of the thighs. 
It is especially prone to extend to and involve the clitoris, geni- 
tals, and vagina, when all sexual desire and pleasurable sensa- 
tion during coition become lost. This condition is particu- 
larly associated with retrouterine inflammation complicating 
retrodisplacement . 

22. Visceral Neuralgias. — The bladder and rectum are not 
alone the seat of pain, but remote organs are also affected, such 
as the liver, stomach, intestinal canal, and heart. Patients not 
infrequently suffer from symptoms which cause them to believe 
themselves the victims of a serious disorder of the heart, which 
entirely disappear upon proper treatment directed to a pelvic 
lesion. 

23. Neuralgia in the lumbar and dorsal regions, — intercostal 
neuralgia of the left side, — leading the patient to fear the exist- 
ence of organic heart disease, is common. The trifacial nerve 
may be involved, producing the sensation of a nail being driven 
into the head. Sympathetic pains are frequently noticed in the 
heart, with a sensation of swelling, especially marked during 
menstruation. I have often observed intense pain in the 
breast associated with a chronic inflammation of the correspond- 
ing ovary. The pain is usually ameliorated or absent during 
menstruation, but aggravated during the menstrual intervals. 

24. Motor and sensory paralysis is not an infrequent con- 
comitant of uterine disorder. It is sometimes difficult to rec- 
ognize its cause. Occasionally it is unquestionably due to 
hysteria, but numerous cases can be cited where the replacement 
of a retroverted uterus has resulted in the rapid restoration to 
health of patients who were apparently suffering from complete 
paraplegia. I have seen a patient in whom the incoordination 
of motion was so marked as to lead to the diagnosis of advanced 
locomotor ataxia recover without a vestige of the disorder 
subsequent to an amputation of a hypertrophied and inflamed 
cervix and the repair of a relaxed pelvic floor. 



16 GYNECOLOGY. 

25. Disorders of Nutrition. — Every physician is familiar 
with the profound influence upon the processes of nutrition fre- 
quently engendered by the occurrence of pregnancy. It does 
not seem unreasonable to anticipate that the substitution of 
a pathologic lesion for a physiologic condition will exert equal 
if not greater disturbance of these processes and an impoverished 
condition of health necessarily results. The conditions which 
will most frequently occur are chlorosis, anemia, and general 
debility. 

26. Chlorosis is found in poorly nourished girls, who suffer 
from it at puberty, or in women during pregnancy, and is often 
a result rather than the cause of the pelvic disorder. 

27. Anemia may occur at any age. In the earlier periods 
of life it may be both a consequent and a cause of pelvic disease. 
It is especially associated with chronic inflammation of the uterus 
and appendages. It is marked in uterine myomata of the inter- 
stitial and submucous varieties, in the various forms of malig- 
nant disease, and in chronic inflammation of the urinary tract. 
Repeated and prolonged hemorrhages, continuous leukorrhea, 
loss of rest from pain, or from frequent micturition are contrib- 
uting causes. The condition is indicated by loss of color in 
the skin, transparency of the tissues, local edema, frequent 
weak pulse, and general debility. These disturbances of nutri- 
tion are accompanied not only by general debility, but also 
by progressive emaciation, until the disorder producing them 
has been corrected. Under the influence of the diseased con- 
dition the patient becomes prematurely aged. The head is 
stooped, the limbs are bent, the features are drawn, and she 
presents a look of suffering; the flesh is soft and flabby; the 
countenance is expressionless, the complexion pale and faded, 
especially when leukorrhea has been long continued and profuse. 
The paleness is different from that of ordinary anemia ; it causes 
the characteristic appearance that has been recognized under the 
name of fades uterina (Courty). Emaciation may not always be 
present; on the contrary, the patient may sometimes be corpu- 
lent, particularly when amenorrhea, rather than leukorrhea or 
hemorrhage, occurs. The obesity is sometimes so great as to lead 
the patient to believe herself pregnant, and not infrequently, 
while suffering severely, she is congratulated by her acquaint- 
ances upon her excellent appearance. 

28. Local Symptoms.— Disturbances of function and dis- 
agreeable sensations which are directly traceable to the genital 
organs and the structures in immediate association with them 
are designated as local symptoms. 

These symptoms comprise: discomfort in sitting, a sensa- 
tion of weight and pressure in standing or walking, heat and 



DIAGNOSIS. 17 

burning in the vagina, pain upon movement, tenderness to 
pressure over the abdomen, frequent and painful micturition, 
more or less profuse discharge, absent, too frequent, irregular, 
and painful menstruation, pain during the act of coition or even 
upon touching the vulva, and a sensation of distress and aching 
following the sexual relation. Reflex phengmena from the 
rectum or bladder, or, on the other hand, sympathetic irri- 
tation of the uterus, when either of the former organs is the 
seat of disease, are very common, and the frequency of their 
occurrence can be appreciated when aa'c remember that the 
nerve supply to the uterus, rectum, and vagina is derived from 
the cervico-uterine ganglia of the hypogastric plexus. 

29. Rectal Reflexes. — It is not unusual to find that during 
menstruation women suft'er from diarrhea, proctitis, and rectal 
tenesmus. The pelvic vascular system is so general that en- 
gorgement or inflammation of the uterus Avill not fail to produce 
congestion in the other pelvic organs; and in any marked in- 
flammation of the organ, associated with displacement, and par- 
ticularly in retrodisplacements, the hemorrhoidal vessels will 
be found to be distended; thus, hemorrhoids in the female very 
frequently result from the presence of retrodisplacements of 
the uterus, and these should never be subjected to operative 
treatment until the displacement has been corrected. In 
anteversion the cervix Avill frequentty be found to project against 
the anterior wall of the rectum, and can be readily distinguished 
through this viscus. When the cervix is inflamed, the im- 
pingement of hard fecal matter against the organ not infrequently 
causes severe pain. In some cases this pain is experienced 
only during menstruation. The most frequent functional dis- 
order of the rectum is constipation; partly from neglect, and 
partly from want of nerve irritation, the bowel becomes fllled with 
fecal matter, the watery portions are absorbed, and hard, dense, 
scybalous masses form, which are evacuated with difliculty, and 
possibly only after repeated enemata. The muscular coat of the 
bowel becomes distended, loses its tone, and results in a form 
of paralysis ; fecal matter undergoes decomposition, is partly re- 
absorbed, and causes the condition which Barnes has denominated 
as copremia, in which the skin is of a sallow, dirty hue, presenting 
ill-smelling secretions; the patient suft'ers from dyspepsia, flatu- 
lence, and pyrosis — a condition akin to that known as uremia. 
The violent efforts at evacuation of the bowels lead not only to 
the formation of hemorrhoids, fissure, sometimes fistula, but they 
may, through the increased intra-abdominal pressure, cause dis- 
placement of the uterus and the vagina. When fissures exist, the 
pain during defecation is so great that the patient is likely to per- 



18 GYNECOLOGY. 

mit the bowels to go unevacuated rather than endure the result- 
ant pain. 

30. Vesical Reflexes. — The relation of the bladder to the 
uterus is more intimate than that of the rectum, and consequently 
this organ is much more likely to be affected in inflammatory 
conditions of the uterus. Retention of the urine may be pro- 
duced by pregnancy or by pelvic growths, such as fibroid tumors 
or tumors of the ovaries. Sometimes also, as a result of irritation 
of the orifice of the vagina, a condition known as vaginismus 
occurs. The pain may be so great as to produce a spasmodic 
contraction of the sphincter of the bladder. The most usual 
functional derangement of the bladder, however, is frequent 
micturition. It may occur as the result of reflex irritation from 
the pelvic organs, or in consequence of pressure from the uterus, 
produced by the presence of a tumor or by a pregnant uterus or a 
displaced organ in which either the fundus rests forward upon the 
bladder or is turned backward, causing the cervix to press against 
the latter. Either of these conditions may lead to functional 
derangement of the bladder, so marked as to cause the patient to 
suspect the existence of disease of that organ, or, as she will more 
probably say, disease of the kidneys. 

31. Genital Symptoms. — The symptoms attributable to the 
genital organs are derangements in the performance of their 
functions. The particular symptoms are disturbances of men- 
struation, such as a decreased, an increased, or an irregular 
menstrual flow, the existence of sterility, the presence of pain 
and excessive discharge ; consequently, in determining the history 
of the patient, if she is married, we endeavor to elicit information 
regarding previous pregnancies and the character of the labors. 
Sterility in a woman who has been married for a number of years 
is an indication of some abnormal condition. It may be due to a 
malformation, to functional disturbances, to actual disease, or 
to efforts to avoid the responsibility of maternity. It should be 
remembered, however, that there are cases of relative sterility. 
The most unvarying function of the uterus is that of menstruation, 
consequently some disturbance in the performance of this func- 
tion is one of the first indications of the existence of uterine dis- 
order. Amenorrhea is a term employed to designate absent 
or greatly decreased menstrual flow; menorrhagia the flow, 
which though regular, is increased, and the menstrual period 
lengthened ; metrorrhagia a flow that does not correspond with 
the regular periods; while dysmenorrhea indicates the existence 
of pain occurring at the beginning of, during, or immediately 
following the menses. These conditions will be considered 
more fully later. 

32. Hemorrhage is by no means a constant symptom of 



DIAGNOSIS. - 19 

Uterine disease. Its significance varies according to the amount 
of blood lost and the time of life at which it occurs. During the 
earlier periods of menstrual life it is not uncomxmon for the menses 
to be very profuse, as a result of defective development of the 
ovaries or ovarian hyperemia. AVhen hemorrhage occurs in 
women who have borne children, it may be produced by inflam- 
mation of the mucous membrane of the uterus — hence a hemor- 
rhagic endometritis. Hemorrhage is a usual symptom of 
fibroid groAvths of the submucous variety. Uterine polypi, 
whether due to a fibroid growth or to vascular growths upon the 
endometrium, are a very prolific cause near the climacteric. The 
occurrence of hemorrhage subsequent to the menopause should 
always cause the ph^^sician to suspect the possibility of malignant 
disease in either the mucous membrane of the cervix or the body 
of the uterus. When hemorrhage occurs during or following 
pregnancy, it is probably due either to a threatened abortion or 
to retention of portions of the fetal envelopes. It should not be 
forgotten, however, that hemorrhage may occur from cystic 
disease of the ovaries, and in some cases in which the pelvic 
organs present no lesion, as from valvular disease of the heart, 
Bright's disease, and obstruction of the portal circulation of the 
liver. The occurrence of hemorrhage should always be re- 
garded as an important danger signal, and should be considered 
as demanding careful investigation to elicit its cause. 

33. Pain is a very frequent symptom, and may be associated 
with the menstrual function, when it is known as dysmenorrhea, 
or may be independent of it. When it occurs during coition, it 
is called dysparennia (Barnes). It may be dependent upon, 
first, vaginismus; second, chronic nervous irritability due to in- 
complete or awkwardly performed first coitus; third, infiam- 
mation; fourth, tumors; and fifth, malformations. 

34. Seats of Pain. — Courty describes six seats of pain, three 
of which are principal and three accessory. The principal seats 
are, first, the iliac regions; second, the loins; and, third, the 
hypogastrium. 

35. The iliac pain is the most frequent ; it is felt in the region 
of the iliac fossa, and extends from it to the hypogastric and 
lumbar regions, particularly toward the pelvic brim and cavity. 
This pain is most often felt upon the left side. It is probably due 
to tension of the broad ligament, and occurs upon the left side 
more frequently on account of the arrangement of the circulation 
through the veins. The left ovarian vein enters the left renal 
at a right angle, and passes behind the sigmoid flexure of the colon 
to reach it. The frequent impaction of this portion of the gut 
with feces would account for the obstructed circulation. 

Courty ascribes pain in this region, hoAvever, to the inclination 



20 GYNECOLOGY. 

of the uterus to the right ; hence any increase in size of the organ 
causes a gradual dragging upon the left broad ligament. 

36. Lumbar pain, generally spoken of as backache, is felt in 
the lower part of the lumbar region, sometimes extending to the 
region of the kidneys, and, in others, and more frequently, down 
over the sacrum. In some cases the abdomen is encircled as 
with a belt of pain. This pain is usually ascribed to traction 
upon the uterosacral ligaments. It is doubtless not infre- 
quently due to retention of secretion w^ithin the cavity of the 
uterus, by which that organ is obliged to go into labor in order to 
secure its expulsion. Its presence indicates disease of the cervix ; 
when it is particularly marked in the sacrum, it is the probable 
result of retrodisplacement of the uterus. 

37. Hypogastric pain is experienced above the pubes, and, 
more than any other, seems to have its origin in the uterus. It 
is elicited artificially, rather than occurring spontaneously. 
Patients w^ho do not experience it ordinarily, complain as soon as 
pressure is made over the lower portion of the abdomen. This 
pain is greatly aggravated in walking, so that the patient not in- 
frequently experiences the necessity of support over the hypogas- 
trium by means of a belt or by placing the hands in front, partly 
for support and partly for protection against injury. 

38. The accessory seats of pain Courty ascribes first to the 
anus or perineum; second, to the vagina or cervix; and, third, 
to the cavity of the pelvis. 

39. The anal or perineal pain is usually produced by a retro- 
uterine tumor or retroflexed uterus. Patients with hypertrophy 
of the cervix not infrequently suffer pain in the anus or perineum 
while walking or riding, and often when sitting. 

40. Vaginal pain is not so frequent. It is felt in women who 
have inflamed uteri, particularly during an orgasm. 

41. Pelvic pain results usually from inflammation about the 
uterus or from inflammation of the tubes, fixation of the ovaries, 
or when organs have become cystic or the seat of pus collections. 

42. Leukorrhea. — Leukorrhea, or whites, is a term given to 
discharges other than sanguineous that occur from the genital 
tract. To appreciate the significance of a discharge as an indica- 
tion of disease, we must recognize the character of the normal 
or physiologic secretion. 

43. The secretion from the Fallopian tubes and cavity of the 
uterus is a thin, whitish alkaline fluid; that from the cervical 
glands is also alkaline, but is very viscid, tenacious, and trans- 
parent like white of egg. 

44. The secretion of the vagina and vulva is whitish, made 
up of a serous fluid intermixed with scaly epithelium. The 



DIAGNOSIS. 21 

vulvar discharge also contains oil-globules from the sebaceous 
glands. The secretion of both vagina and vulva is acid. 

The superfluous discharge from the cervix is coagulated by 
that of the vagina, forming a smeary material at the upper part 
of the vagina, and will be found to coat over the surface of a 
pessary. When the cervical fluid is in excess, it may pass from 
the vagina unchanged and perfectly transparent. 

Another discharge or secretion is that which takes place from 
the vulvovaginal glands during coition or under excitement. 
This is a clear, viscid discharge. In very erotic women this dis- 
charge is ejected upon the approach of a person of the opposite 
sex, and nocturnal discharges occur during erotic dreams. 

It is sometimes difficult to determine whether a discharge is 
the result of over -stimulation of a physiologic secretion, or is pro- 
duced by a pathologic condition. 

45. Catarrhal Discharge. — A profuse discharge is not an 
infrequent result of exposure to cold. An increased secretion 
from the uterine glands occurs instead of the ordinary nasal flow. 
A hypersecretion which results from the hyperemia of the preg- 
nant uterus may be considered physiologic. 

In some undeveloped and strumous young women a leukor- 
rhea occurs as a substitute for the menses. In many individuals 
a slight leukorrhea, preceding or following the menses, has no 
abnormal significance. 

46. Origin of Discharge. — The source of origin of an abnormal 
discharge can be determined to some degree by its appearance 
and character. When from the cavity of the uterus, it will be a 
thin, watery fluid, loaded with ciliated columnar epithelium, and 
containing also pus and blood-corpuscles, according to the extent 
of the disease. 

47. Discharge Simulating Abscess. — The discharge may be 
a continuous flow, but more frequently it is intermittent, due to 
defective drainage from swelling of the mucous membrane of 
the outlet, which leads to dilatation of the cavity and not in- 
frequently of the orifices of the tubes. The uterus then empties 
itself only by occasionally going into labor to evacuate its con- 
tents. Such a fluid, loaded with pus and blood-corpuscles, 
coming away in gushes, leads the patient to believe that an 
abscess has formed and been evacuated. Patients will not 
infrequently inform you that they have abscesses form and 
discharge at short intervals. The conditions described, however, 
may not be the only explanation. An accumulation in a tube, 
the uterine end of which is still patulous, may occasionally drain 
through the uterus. Such a condition has been denominated 
hydrops tuhce profiuens. 

48. Other sources for purulent discharges are found in the 



22 GYNECOLOGY. 

rupture and escape into the vagina of the contents of a tubal 
or peritoneal abscess, of a suppurating ovarian tumor, of an 
extra -uterine pregnancy sac, or of an abscess about the vermi- 
form appendix. 

49. Cervical Discharge. — The discharge from the cervix is 
usually very viscid and tenacious ; it may be clear and transparent, 
or clouded by desquamated epithelium and filled with pus-cells, 
when it is yellowish or greenish-yehow in color, or it may be 
a dirty brown from admixture Avith blood-corpuscles. 

The cervix will usually be dilated and patulous, its membrane 
thickened, abraded, and covered with papillae. 

50. Vaginal Discharge. — A thin, serous discharge flows from 
the vagina in simple inflammation; in more severe attacks it is 
loaded with epithelium, and the vagina is red and inflamed and 
has apparently shed its entire epithelial coat. When due to 
gonorrhea, the discharge is profuse, purulent, ichorous, irritating 
to the external parts, and attended with a burning sensation 
during micturition. 

51. Effect of Age upon the Discharge. — The significance of the 
discharge is also dependent upon the age and physical condition 
of the patient. Prior to puberty it is usually due to irritation of 
the vulva, and is thin and serous, resembling that from eczema. 
After puberty, in the unmarried, it is generally vaginal. In the 
more mature and in married women it is usually uterine. 

As the individual approaches puberty the vulvar discharge 
becomes more oleaginous from the secretion of the sebaceous 
follicles. Not infrequently, in uncleanly persons, the secretion 
from these glands is so abundant that it decomposes and sets up 
an inflammation similar to the blennorrhea of the male. Prior to 
or following the climacteric a thin, watery flow, of a sweetish, 
sickening, or decayed-flesh-like odor, should be considered a 
strong premonition of cancer of the uterus. 

52. Physical Signs. — The careful study and analysis of the 
subjective phenomena may afford an approximate idea of the 
disorder present, but the diagnosis should not be attempted 
until the objective symptoms, or physical signs, have been in- 
vestigated. 

53. Senses Employed. — In the study of the physical signs all 
the senses except that of taste are employed : 

The sight is used in inspection of the abdomen and external 
genitalia and in examining the internal organs by the use of the 
speculum. 

The touch is practised in abdominal palpation and percussion, 
in simple vaginal or rectal touch, in conjoined manipulation, and 
in the use of sound or catheter. 

The hearing is employed in percussion and auscultation. 

The smell is exercised in the examination of discharges. 



DIAGNOSIS. 



23 



54. Examination. — The investigation of the physical signs 
is called an examination and may be made through the vagina, 
rectum or' urethra, or a combination of one or more of these 
with pressure over the abdomen. 

55. Pelvic examination comprises inspection, touch, and in- 
strumental investigation. 

56. Abdominal examination may be classified under inspec- 
tion, palpation, percussion, auscultation, and exploratory punc- 
ture or incision. 

57. Preliminaries. — The verbal examination should have been 
so conducted that upon its completion the patient will be im- 
pressed w^ith the fact that a physical examination is the only 
logical conclusion. The examination may be made upon a sofa 
or a common bed, as would be the custom when made at the 
home of the patient ; but in office practice it will be found more 
convenient to have provided a suitable table or chair. The 
choice of table will depend 

upon the custom and conve- 
nience of the operator. One 
made by Codman & Shurtleff , 
of Boston, known as the 
Chad wick table, is very satis- 
factory. (Fig. I.) In the 
first examination for the con- 
sideration of obscure condi- 
tions the clothing should be 
loosened and corsets removed, 
so that the abdominal walls 
can be completely relaxed. 
The bladder and rectum 
should be empty. The latter 

suggestions are very important in order to permit_ the normal 
relations of the uterus and its adnexa to be determined. Fecal 
accumulations have been mistaken for ovarian and tubal en- 
largements or inflammatory exudates. A distended bladder has 
been confounded with an ovarian tumor. The patient should 
be so placed for examination that the pelvis will be exposed to 
a good light. 

58. Positions. — The patient may be placed in one of six 
positions for examination: viz., (i) dorsal; (2) lateral; (3) semi- 
prone (Sims); (4) genupectoral ; (5) Trendelenburg; (6) erect. 
Of the positions named, the dorsal and Trendelenburg are the 
most important. 

59. The Dorsal Position. — The patient lies upon her back, 
with the hmbs flexed and feet placed upon supports. The feet 
may be on a level with the buttocks or placed on supports a 




Fig. I. — Chadwick Table. 



24 



GYNECOLOGY. 



foot higher. The latter affords greater relaxation to the ab- 
dominal muscles. The clothing is lifted over the knees. The 
lower part of the body has been previously covered with a 
sheet, which is folded about the widely separated limbs, and 
permits the inspection of the vulva. (Fig. 2.) This position 
permits the ready practice of the bimanual examination, 
and is the most favorable for vaginal and abdominal palpation 
and for the use of the valvular and Edebohls' specula. For 
operative procedure the dorsal position may be favorably modi- 
fied by strongly flexing the legs upon the body, in which posture 
they may be retained by assistants, or the employment of a 
suitable leg holder. 

60. The Lateral Position. — The patient lies upon the left 

side, with the limbs at a 
right angle to the body. 
This position was formerly 
much used by English gy- 
necologists, and was pre- 
ferred because it permitted 
examination to be made 
without danger of touching 
the tender structures at 
the anterior part of the 
vulva. This position was 
thought less vulgar, and it 
allowed the finger to follow 
more readily the curve of 
the sacrum and to reach 
with greater ease the highly 
situated cervix. Its chief 
advantage, however, is in 
permitting more minute in- 
vestigation of the lateral 
fornices of the vagina. In 
abdominal palpation it affords increased opportunity to recog- 
nize changes of position of tumors and displacements of the 
viscera, particularly of the kidney. 

61. The Semiprone or Sims* Position (Fig. 3). — The patient 
is placed upon the left side and chest, with the left arm behind 
her, the left leg partly extended , the right being flexed at a right 
angle to the body. The intra-abdominal pressure is neutralized. 
The mobiHty of the uterus is readily determined, replacement 
more easily accomplished, and some anteflexions recognized as 
the organ falls forward that are not apparent in any other posi- 
tion. The chief value of the position is in the use of the Sims' 
speculum. 




Fig. 2. — Dorsal Position. 



DIAGNOSIS. 



25 



62. The genupectoral position (Fig. 4), also called the knee- 
chest position, is one in which the patient rests upon the chest and 
knees. The left side of her face rests upon her left hand. The 




Fig. 3. — Sims' Position. Proper Method of Holding the Specukim. 

thighs are at right angles to the surface of the table. The chief 
value of this position is in replacing a retrodisplaced uterus or 




Fig. 4. — Genupectoral Position. Organs Shown in Outline. 



prolapsed ovary, or for elevating from the pelvis a more or less 
impacted tumor. 



26 



GYNECOLOGY. 



63. The Trendelenburg Position. — The patient lies upon her 
back and on a plane inclined at an angle of 45 to 60 degrees, with 
the feet and legs ovei: a flap of the table. (Fig. 5.) Heavy patients 
should have additional support by the application of shoulder 
pieces. Pryor modified the position by supporting the patient 
from the shoulders and flexed the legs upon the body for the pur- 




Fig. 5. — Trendelenburg Position. 



pose of examination of the pelvic viscera free from the intestines, 
which gravitate upward when free to do so. This posture is 
of especial value in cystoscopic investigation of the bladder. 
The greatest value of the Trendelenburg posture is in the free- 
dom of view afforded in abdominal section, permitting the 
operator to employ the sight as well as touch in the manipulation. 



PELVIC EXAMINATION. 27 

64. The erect position is of limited application. The patient 
stands with feet separated, with one hand resting upon the 
shoulder of the physician, while he sits or kneels before her and 
introduces the index-finger into the vagina. The chief value of 
this position is in determining the amount of downward displace- 
ment of the pelvic contents and in securing ballottement in the 
early stages of pregnancy. 



PELVIC EXAMINATION. 

65. Inspection. — The patient is placed in the dorsal position. 
(Section 52.) In the first examination of every patient a visual 
examination should always precede the practice of touch. By 
carefully arranging the clothing this can be done without shock- 
ing the sensibility of the most modest. It affords information as 
to the cleanliness of the patient ; the presence of pediculi ; venereal 
warts or sores ; malformations ; traumatisms ; eruptions upon the 
vulva; tumors of the labia majora; elongation and thickening ot 
the labia minora; hypertrophy of the clitoris; elongated or ad- 
herent prepuce ; lacerations of the perineum ; presence of hemor- 
rhoids, ulcerations, or fissures; urethral caruncle; anomalies of the 
hymen; cystocele; rectocele; prolapse of the uterus; and the 
quantity and character of vaginal discharge. Inspection may be 
a simple preliminary to the touch. 

66. Simple Touch. — The pelvic floor presents three apertures 
or perforations: the urethra, the vagina, and the anus — through 
either one or all of which an exploration may be made. The 
vagina is the route usually chosen as affording the best oppor- 
tunity for securing the most extended information. 

67. Preparation. — The hands should be carefully cleansed. 
Independent of any possible danger of conveying infection, the 
educated woman will be doubtful of the physician who proceeds 
to her examination with unclean hands and nails. The latter 
should be cut close. Either hand may be used in examination. 
In some cases it may be desirable to use first one and then the 
other. When the vagina is sufficiently roomy, two fingers should 
be introduced. This affords additional length and surface for 
touch. The fingers should be lubricated with soap or some un- 
guent, such as carbolized alboline. The soap is preferable, for 
in washing it is removed with the secretions ; but in some patients, 
however, it aggravates any existing irritation. 

68. Procedure. — The physician with one hand separates the 
vulva in order to avoid carrying up the hair, and holds the labia 
separate as he proceeds to make the digital investigation. Press- 
ing back the perineum, the finger or fingers more easily enter, 



28 



GYNECOLOGY. 



and without impinging against the anterior delicate structures. 
The perineum may be depressed with the index finger while the 
middle finger is inserted above it, thus permitting the employ- 
ment of two fingers with but little discomfort. The unemployed 
fingers of the hand can be carried back, either extended or 
closed, but the latter shortens the distance accessible to touch. 
(Fig. 6.) The touch affords information as to the presence of cysts 
in the labia ; the size of the vagina ; relaxation of its walls ; condi- 
tion of its mucous membrane; amount of secretion; the con- 
tents and tenderness of the rectum; inflammation and projec- 
tion of the urethra; tenderness, prolapse, and distention of the 
bladder; and relation of the uterus to the vaccinal axis. In 




Fig. 6. — Proper Position of Fingers for Examination. 

its normal position the cervix looks backward, the axis of the 
uterus being nearly at right angles to that of the vagina. The 
situation, size, and density of the cervix are recognized. It 
may be normal, lacerated on one or both sides, or. present a 
number of fissures — a stellate laceration. Its lips may be soft 
and velvety, from enlarged papillse; nodular, from enlarged 
or cystic Nabothian glands; widely everted and dense, from 
chronic inflammation following laceration; enlarged and indu- 
rated, from chronic inflammation or malignant infiltration ; en- 
larged, friable, or excavated in epithelioma. The os will be a 
slightly transverse depressed dimple when normal, or when 



PELVIC EXAMINATION. 29 

abnormal, will be fissured laterally, bilaterally, through the 
anterior or posterior lip, or in a number of directions. It may 
be firmly closed or may stand open to such a degree as to ad- 
mit the finger. The spaces about the vaginal projection of 




Fig. 7. — Half Section of the Pelvis with Patient Erect, Showing Normal Position 
of the Uterus. — (Deaver.) 

the uterus are known as the fornices. The posterior fornix 
is the deeper; the anterior is slight. The resistance and density 
recognized indicate the existence or absence of inflammation. 



30 GYNECOLOGY. 

A mass in the posterior fornix, if continuous with the cervix, 
the axis of which is paraUel to that of the vagina, is a retro- 
version of the uterus. If there is an angle between it and 
the cervix, the condition may be a retroflexion of the uterus, a 
tumor of the posterior uterine wall, an enlarged ovary or tube, or 
an inflammatory exudate. Digital examination also affords an 
idea of the mobility of the uterus, but the investigation is con- 
fined to the lower segment. 

69. Bimanual procedure, also called the conjoined manipu- 
lation, or vagino-abdominal touch, affords definite informa- 
tion. In every examination the introduction of one or two 
fingers into the vagina should be associated with the application 
of the fingers of the other hand upon the abdomen. The external 
hand may be placed about midway between the symphysis and 
umbilicus, pressing downward upon the anterior abdominal wall. 
It may be moved from one side to the other, in order to examine 
the contents of the pelvis. This procedure enables us to outline 
the size, shape, density, and situation of the uterus, and to deter- 
mine the presence of growths in its walls and its relation to other 
pelvic growths or to inflammatory deposits. The normal tube is 
rarely palpable. When it is readily perceived, it has been the 
seat of an inflammatory condition. The ovaries are more 
easily recognized. To arrive at a definite conclusion in an 
obscure case, it is better to introduce into the vagina one or 
two fingers of the hand corresponding to the ovary to be palpated, 
as the extreme rotation necessary to bring the sensitive surface of 
the finger in contact with a small mass diminishes the sense of 
perception. (Fig. 8.) 

70. Difficulties. — The bimanual examination is rendered diffi- 
cult by a large deposit of fat in the abdominal wall and by 
rigidity of the abdominal muscles. The latter is sometimes so 
marked that the patient can not relax the muscles, and the deter- 
mination of the pelvic condition is unsatisfactory. When this 
is due to nervousness, much can be accomplished by allaying the 
patient's fears and securing her cooperation. Have her breathe 
with the mouth open, fill her lungs, and then expel the air, while 
the hand over the abdomen depresses the wall during expiration, 
and thus secures an outline of the pelvic organs. The procedure 
may sometimes be rendered less difficult by diverting the patient's 
attention through inquiries regarding other symptoms. When 
the resistance can not be overcome, or the sensitiveness arises 
from an inflammatory condition, or the abdominal walls are very 
fleshy, an anesthetic may be necessary. 

71. Virgins. — It is often a serious question to determine when 
an examination should be made upon a young unmarried woman. 
It should be the rule to avoid such an examination, unless the 



PELVIC EXAMINATION. 



31 



symptoms are of such a character as to indicate the existence 
of conditions which endanger her health. The regular occurrence 
of menstrual molimina, without the appearance of bloody dis- 
charge, after the age when puberty should be expected, must be 
considered an indication for a physical investigation. In many 
patients requiring a digital examination the procedure can be 
accomplished through the rectum. Where a vaginal examina- 
tion by the finger seems indispensable, the discomfort can be 



^^PK»„ 




Fig:. 8. — Bimanual Examination. 



lessened by carefully lubricating the examining finger and 
directing the patient to bear down as it is being introduced 

72. Rectal Touch. — (The rectal touch, recto-abdominal [Fig. 
9], rectovagino-abdominal, or rectovesical touch.) The routine 
practice of digital examination by the rectum in the first in- 
vestigation of a patient is to be commended. The finger should 
be carefully washed after removal from the vagina and before its 
introduction into the rectum, and vice versa. Neglect of this 



32 



GYNECOLOGY. 



precaution may lead to a severe proctitis from the introduction 
of infectious material. The anointed finger, first directed for- 
ward, and after its entrance carried baclrv^^ard, is gently rotated. 
It enables us to recognize the condition of the rectum ; the pres- 
ence of fissures; hemorrhoids, ulcerations; contractions of the 
sphincter; sensitiveness of the coccyx; encroachment upon the 
bowel by the uterus ; the condition of the posterior surface of that 
organ; the presence of inflammatory exudate in the pelvis; 
malignant infiltration of the broad ligaments or peritoneum; 




9. — Recto-abdominal Palpation. 



and the position of the uterus, when we desire to avoid a vaginal 
examination of the virgin. The rectal procedure promotes the 
replacement of the displaced organ. The correction of malposi- 
tions is facilitated by the introduction of the middle finger into 
the rectum and of the index-finger or thumb into the vagina. 
(Fig. 10.) The conjoined. rectal manipulation is known as the 
recto-abdominal, the rectovaginal, the recto vagino-abdominal, 
or the rectovesical, according to the position of the fingers of the 
two hands. The absence or presence of the uterus in congenital 



PELVIC EXAMINATION 



33 



atresia vaginalis may be determined by rectovesical touch; that 
is, the introduction of the finger into the rectum and of a sound 
(Fig. ii), bougie, catheter, or finger of the other hand through 
the urethra. It is rarely that it will be necessary to explore the 
bladder with the finger. 

73. Simon's method consists in the introduction of the whole 
hand into the bowel, and is capable of affording additional in- 




^- 



Fig. 10.— Rectovagino-abdominal Palpation. Index-finger of one hand in the 
rectum, thumb in the vagina, and the fingers of the other hand over the 
abdomen. 



formation as to the condition of the pelvic organs. Such serious 
injuries have resulted from its practice, however, that it is now 
considered an unjustifiable procedure, unless the surgeon has an 
exceedingly small hand. 

74. Vaginal Section. — Ferguson advocates exploration of 
the abdominal viscera by an incision through the posterior 

3 



34 GYNECOLOGY. 

vaginal fornix as preferable to the exploratory abdominal in- 
cision. It is true that such an investigation can frequently 
be made; that it avoids the prolonged convalescence from an 
external incision, but its practice will frequently result in a 
weakened pelvic floor which will subsequently prove an in- 
effective barrier to vaginal hernia. 

75. Precautions. — It would be unwise to dismiss the subject 
of bimanual examination without a word of caution. The pro- 
cedure should always be exercised with care not to do injury. 
Anxiety to arrive at a correct diagnosis may lead to rupture 
of a tubal collection or an ectopic gestation sac, and to the 
necessity for prompt operation to save life. I have seen two 
patients, and have been informed of others, in whom examination 
has been followed by rupture of ectopic gestation sacs, with 
death from internal hemorrhage. 




'^& 




Fig. II. — Rectovesical Palpation. Sound in Bladder. 

76. Instrumental Examination. — The order generally rec- 
ommended for the employment of instruments has been: First, 
the use of the sound and then of the speculum. The difficulty, 
however, in rendering the vagina sterile has justly led to the 
reverse procedure. The sound is a long, flexible instrument, 
twenty-five centimeters in length, two or three millimeters in 
diameter, terminating in a bulbous end, and generally has a 
slight elevation about six centimeters from its end, which in- 
dicates the normal length of the uterine cavity. For conveni- 
ence in measurement its posterior surface is marked by a scale 
in inches or centimeters. The instrument should be perfectly 
smooth, having no notches or indentations which may serve 



PELVIC EXAMINATION. 



35 



to retain infection. It is made of silver, or copper (silver or 
nickel plated), and should be sufficiently flexible to admit of 
its being readily bent. The handle should be roughened upon 
one side so that the concavitv of the instrument can ahvavs 




^_^^.:-^|_^^^=_^^^_ 



Fig. 12. — Simpson's Sound. 

be determined. Such an instrument is known as Simpson's 
sound. Sims advocated the use of a finer and more flexible 
instrument, known as the probe. 

77. Probes are made of metal, hard rubber, and whalebone. 







Fig. 13. — Sims' Probe. 



The metal probe may be made of twisted steel and covered 
with a rubber sheath, rendering it more flexible. (Fig^ 15.) 
The uses of the sound or probe are to ascertain the patency of 
the cervical canal, the depth of the uterus, its width or capacity, 



Fig. 14. — Whalebone Probe. 

the thickness of its walls, the presence of intra-uterine tumors, 
the condition of the mucous membrane, the direction -of the 
uterine canal, and the mobilitv of the uterus. In treatment 
it has been used to replace the displaced uterus. The experi- 



s^ 



Fig. 15. — Spring Probe Covered with Rubber. 



enced ph^^sician will be able to obtain much of this knowledge 
fully as effectually by the bimanual examination, and in the 
majority of cases the disadvantages of the instrument greatly 



36 



GYNECOLOGY. 



outweigh the value of the information obtained by its use. 
It affords knowledge as to the patency of the canal which can 
not otherwise be determined; in all other instances the omis- 
sion of its use is preferable to its employment. It is true it 
is capable of affording information as to the direction of the 
uterus Avhen the situation of that organ is rendered doubtful 
by the presence of inflammatory exudate, but in such cases 
its use is contraindicated. Our inability to secure an aseptic 
vagina should lead to the introduction of the instrument through 




Fig. 1 6. — Introduction of the Sound. 



the Speculum, and then only after the vault of the vagina has 
been carefully mopped with absorbent cotton wet with a 2 per 
cent, solution of formalin. It is almost impossible to introduce 
the instrument without injuring the mucous membrane of the 
uterine cavity, an injury which will afford a favorable culture- 
field for the development of germs which are found in the vagina, 
or, exceptionally, even in the cervical canal. Such injuries 
explain the inflammatory irritation following the use of 
the sound and still further demonstrate the wisdom of dis- 



PELVIC EXAMINATION 37 

continuing its employment for replacement of the uterus. When 
it seems desirable to use the sound without the speculum, the 
vagina should be previously scrubbed and two fingers 
introduced to the cervix, by which the sound is guided into 
the OS. (Fig. i6.) No force should be employed and the in- 
strument should have such a curve as will permit it to pass 
readily in the direction which a bimanual examination has dem- 
onstrated should be that of the uterine cavity. 

78. Precautions. — The date of the last menstruation must 
be known, and the use of the instrument should be avoided when 
there is the slightest suspicion of pregnancy. It should not be 
employed in the presence of acute inflammation or when inflam- 
matory exudate or old infiltrations can be determined. Its em- 
ployment in a case of malignant disease may lead to dangerous 
hemorrhage. In the uterus softened and rendered friable by 
inflammation the sound may penetrate its wall and enter the 
abdominal cavity. This accident produces no inconvenience 
unless the instrument carries infection. The sound may also 
pass into a Fallopian tube. 
This is m*ore likely to occur 
in a bicornate uterus. The 
instrument should be scru- 
pulously clean , indeed, 
should be sterilized by 
boiling, or when this is 

inconvenient be removed Fig- 17.— Ferguson's Speculum. 

from a 5 per cent, solution 

of carbolic acid prior to its use. After its use the instrument 

should be sterilized by heat. 

79. Speculum. — A patient placed in the dorsal position, with 
the limbs separated, reveals the mons veneris, with the larger 
labia. The latter are separated by a cleft or slit — the rima 
pudendum. Frequently the labia minora are elongated, and 
they, with the clitoris, are prominent. The posterior commissure 
may have been injured, and, instead of a slit, we will have a 
triangular opening, through the posterior part of which projects 
the vaginal wall. In lacerations of the pelvic floor its posterior 
segment may be drawn back, permitting one or two inches of 
the vagina to be inspected. By hooking back the vagina with 
two fingers the cervix can frequently be seen. The necessity 
for satisfactory inspection of the uterus led to the invention of 
the speculum. A great variety of instruments for this pur- 
pose have been devised, but all may be classed in two divisions: 
the tubular and the valvular. 

80. The tubular speculum, known as the Ferguson speculum, 
may be made of glass, wood, rubber, celluloid, or metal. The 




38 



GYNECOLOGY. 




Fig. 1 8. — Milk-glass Specula. 



instrument is cylindric, the external end with a flange, the inter- 
nal beveled, and having one long side. (Fig. 17.) Glass instru- 
ments may be made of milk-glass (Fig. 18), as the German 
speculum, or such covered with quicksilver, and over this a 
coating of pitch or rubber. Such specula can not be sterilized 
by heat ; glass is brittle, easily broken, and is subsequently use- 
less. They are very ser- 
viceable in making appli- 
cations to the cervix, but 
only the wooden instru- 
ments are utilizable for the 
use of the actual cautery. 
The application of medica- 
ments to the uterine canal, 
or the use through it of 
the sound, are to be con- 
demned. The tubular 
speculum is not self -retain- 
able. Its range of appli- 
cation is so limited that it 
is now infrequently used. 
To introduce this instru- 
ment the physician separates the labia with the left hand and 
holds the speculum with the right thumb and middle finger on 
either side and the index-finger upon its upper surface. The 
longer side is placed against the posterior commissure of the 
vulva, which is depressed, and the speculum is pushed upward 
and backward, at the same time rotating the instrument so that 
its shorter side does 
not impinge against 
the tender anterior 
structures. The 
situation of the cer- 
vix has been pre- 
viously located by 
the touch. If the 
cervix is not brought 
at once into the field 
of the speculum, it 
can usually be ex- 
posed by rotating 
the instrument. When this procedure fails, it may be drawn 
into the field by a tenaculum. If the cervix is large, only a 
part of it can be exposed at one time, and consequently a dis- 
torted idea of the condition is frequently obtained. 

81. Valvular Speculum. — The valvular speculum may have 




Nott's Speculum. 



PELVIC EXAMINATION. 



39 



one or more valves, and is called univalve, bivalve, tri valve, 
and quadri valve, according to the number of its blades. These 





Fig, 2 1. — T alley's Speculum, 



Fig. 20. — Higbee's Specula (three sizes). 

specula afford a much better exposure and are self-retaining 
therefore, they have largely 
supplanted the tubular in- 
strument. The quadri valve 
instrument is now rarely 
used, as it affords but slight 
additional advantage over 
the bivalve, and besides it 
is difficult to keep clean. 
The Nott (Fig. 19) and 
Nelson specula have three 
blades and afford an oppor- 
tunity to inspect the an- 
terior vaginal wall. The bivalve speculum is the most satis- 
factory for general use. Of the great variety of specula, Hig- 
bee's (three sizes) (Fig. 
20), Talley's (Fig. 21), 
and Goodell's (Fig. 22) 
are probably the most 
satisfactory. The 
blade should be from 
7.5 to II centimeters 
in length. When the 
vaginal portion of the 
cervix is short, the 
Higbee speculum, which has a long posterior blade, will not ex- 
pose the OS. In such cases the Goodell or Talley specula, with 




Fig. 22. — Goodell's Speculum. 



40 



GYNECOLOGY. 



blades of equal length, are better. The speculum is introduced 
by separating the vulva with the fingers of the left hand, while 

the instrument, held 
in the right, is intro- 
duced with its trans- 
verse diameter parallel 
to the long diameter 
of the vulva. As the 
widest diameter of the 
vagina is at right an- 
gles to that of the 
vulva, the instrument 
is rotated and car- 
ried upward, directing 
the blades behind the 
cervix, the position of which has been previously determined by 
a digital examination. As the blades are separated the cervix is 




Fig. 23. — Sims' Speculum. 




^ 



Fig. 24. — Proper Method of Holding Sims' Speculum. The cervix brought into 
view with the tenaculum. 



generally exposed. In marked anteversion it may be necessary 
to use a tenaculum to bring the cervix into view. The speculum 



PELVIC EXAMINATION. 



41 



is a therapeutic instrument, although it confirms the diagnosis 
which has been made by digital examination. 

82. The univalve or duck-bill speculum (Fig. 23), introduced 
by Sims, is used with the patient in the semiprone position. The 
instrument has two blades at either end of a handle, which are 
about 10 centimeters long, the smaller blade being 1.5 centime- 




Fig. 25. — Sims' Depressor. 



Fig. 26. — Goodell's Tenaculum. 



ters and the large blade 4 centimeters in width. To introduce 
this instrument the physician raises the buttock, passes the blade 
with its width parallel to the vulva, and after its entrance 
rotates it with the handle directed backward. The assistant 
then holds the other blade with the right hand, using the in- 
strument as a retractor. (Fig. 24.) His elbow is held against 
his hip, while the left arm 
rests upon the patient, 
the hand elevating the 
buttock. Care must be 
exercised to follow the 
curve of the sacrum or 
the instrument will slip 
out. As the perineum is 
drawn back the vagina is 
ballooned by the atmos- 
pheric pressure and the 
cervix and upper vagina 
are exposed. When the 
vagina is large, with re- 
laxed walls, the cervix 
may be obscured from 
view. The depressor 
(Fig. 25) to push back 

the anterior wall or a tenaculum (Fig. 26) hooked into the cervix 
will overcome the difficulty. The univalve speculum affords a 
better exposure of the cervix and upper portion of the vagina 
than any other form of instrument. Its particular disadvantage 
is that it is not self-retaining, and in office practice requires 




Fig. 27. — Self-retaining Sims Speculum. 



42 



GYNECOLOGY. 



the assistance of a nurse. Various devices (Fig. 27) have been 
instituted to render it self-retaining, but they require con- 
siderable time for their use. In operating with the patient in 
the semiprone position, the irrigating fluid and blood run 
forward, between the patient's limbs, and hence render it 




Fis:. 28. — Simon's Retractors. 



difficult to keep her person and clothing clean. The Sims 
speculum can be used with the patient in the lithotomy- 
position, but it is uncomfortable to hold. The Simon posterior 
and side retractors serve a similar purpose. (Fig. 28.) The 
perineal retractor known as the Edebohls speculum (Fig. 29) is 




Fig. 29 — Edebohls' Speculum. Fig 30. — Edebohls' Speculum m Position. 



the most satisfactory. With the patient upon her back, and the 
limbs acutely flexed, the perineum is retracted and held back 
by a weight attached to the instrument. (Fig. 30.) The cervix 
and the upper and anterior vagina are thus exposed to manipu- 
lation. 



PELVIC EXAMINATION. 



43 



83. Uterine Fixation and Downward Traction. — Reference 
has already been made to the use of the tenaculum to bring the 
cervix into the field of the speculum. The same instrument, or, 
better, a double tenaculum known as bullet-forceps (Fig. 31), 
guided to the cervix by the finger, may be used to fix the organ, 
or in some cases to exert traction (Fig. 32) upon it during digital 



_jO 




Fig. 31. — Double Tenaculum Forceps. 

examination. Such a procedure enables us to examine through 
the rectum the whole posterior surface of the uterus and even to 
pass the finger over its fundus. It is utilized in replacing the 
retroverted and retroflexed organ and in differential diagnosis 
of abdominal and pelvic growths. 

84. Dilatation of the Uterus. — It is frequently necessary to 








Fig. 



32. — Traction vipon Uterus with Double Tenaculum durin« 
ination by the Rectum. 



Digital Exam- 



explore the cavity of the uterus, either to complete the diagnosis 
of a condition rendered probable by other procedures or as a 
preliminary to an operation. The method of operation may be 
divided into two classes: (i) Bloodless — tents, divulsion, and 
gradual dilatation; (2) by incision of the external os and bilateral 
incision of the cervix. Before the practice of any of these pro- 



44 



GYNECOLOGY. 



cedures the presence of inflammation in the organ or vestiges of 
inflammatory exudate about it should be excluded. The existence 
of such conditions presents an element of serious danger. 

85. Dilatation by Tents. — The use of tents was formerly very 
popular and a general method of dilatation. The materials used 
for this purpose were sponge, laminaria, tupelo, slippery elm, 
decalcified ivory, and gentian root. The sponge has the greatest 
dilating power, but is the most difficult to render aseptic and to 
maintain in that condition. The frequent unfortunate sequelae 
that followed their use have larg^elv led to their discontinuance. 




Fig. 33- — Hollow Laminaria Tent. 

The laminaria (Fig. ;^t,) and tupelo tents are the most used. The 
former may be introduced in nests. Their dilating power is 
enhanced by having them hollow. A number of small ones to fill 
up the canal is to be preferred to one large tent. They may be 
rendered aseptic by subjection to a dry heat of 250° F. The 
tent should be placed in an envelope before its introduction into 
the sterilizer, and the envelope should be broken only when it is 
to be used. The tents may also be rendered safe by immersion 
prior to their use in a saturated solution of iodoform in ether. 
Pozzi advocates their immersion in equal parts of carbolic acid 
and alcohol. They may be placed in 95 per cent, carbolic acid 




Fig. 34. — Uterine Forceps — Dressing. 



for a few minutes and afterwards washed in alcohol before in 
sertion. I prefer immersing the laminaria tent in tincture of 
iodin for a few minutes before its employment. The vagina 
and cervix should be carefully cleansed with an antiseptic 
solution ; the cervix is seized through the speculum with bullet 
forceps, while the tents are held in (Fig. 34) dressing forceps, 
and introduced, one after another, until the canal is filled. 
Care must be exercised to mold the tents to the curve of the 
canal, and no force should be employed in their introduction. 
The tents should project from the external os, and should be 



PELVIC EXAMINATION. 45 

held in place by a tampon of iodoform gauze. They should 
be removed at the end of ten or twelve hours. They are removed 
by pulling upon a string fastened to the end of the tent. Re- 
moval is sometimes rendered difficult by irregular dilatation; 

the internal os, being more resistant, causes an hour-glass- 




I^ig- 35- — Dilated Tent Showing Constriction from Internal Os. 

shaped distention. (Fig. 35.) The tent is removed by plac- 
ing the finger against the cervix during traction. The irreg- 
ular dilatation is less likely to occur with a tupelo tent, though 
its dilating power is not so great. Pain during the dilatation 
can be relieved by the use of from two to five grains of acetanilid 




Ellinger's Dilator. 



or from J to ^ of a grain of codein. The removal of the tent 
should be followed by careful antiseptic irrigation, after which 
another tent or series of tents may be introduced. The use of 
the tent affords an opportunity to make a digital exploration of 
the uterine cavity, and is of advantage in small submucous 




Fig- 3 7- — Goodell's Modification of Ellinger's Dilator. 

fibroids, in suspected epithelioma, and in retained products after 
abortion. 

86. Divulsion consists in the rapid dilatation of the uterine 
canal by the various dilating instruments. The preferable in- 
struments are the parallel bar dilators, such as the Ellinger 



46 



GYNECOLOGY. 



(Fig. 36), with the Baer and Goodeli modifications (Fig. 37); 
the latter, with its roughened blades, is a powerful instrument. 
The vagina and cervical canal are carefully cleansed, and 
through the speculum the cervix is seized with a double tena- 
culum and stretched with small dilators, and subsequently with 
the large instrument to the extent of tw^o or three centimeters, 
if desired. The principal objection to the procedure is that the 
pressure is confined to the lateral surfaces of the cervix and, 
therefore, may lead to laceration. 

87. Gradual dilatation is accomplished by the use of graduated 
bougies, made of steel or hard rubber. The former are prefer- 
able, as they can be sterilized by heat. The Pratt series of 
bougies, which have two bougies to each handle, making eighteen 
in the set, the maximum being No. 43, will be useful. (Fig. 38.) 
Each bougie is two millimeters larger than the preceding. After 
thorough cleansing of the vagina and cervix the Edebohls specu- 
lum is introduced, 
the cervix is seized 
with vulsellum or 
double tenaculum, 
and the bougies are 
used one after an- 
other, up to the 
largest size. (Fig. 
39.) Care should be 
exercised not to 
puncture the uterine 
wall. This accident 
is more likely to oc- 
cur in acute flexions ; 
the point of the in- 
strument makes so much pressure upon the thin convex wall 
near the flexion that it finally ruptures. Rupture or perfora- 
tion of the uterine wall is not of infrequent occurrence, and 
when done by the bougie is of but little significance. The 
tear by the parallel bar dilators is much more serious, as the 
wall of the uterus is torn, just as wide as the dilators have sepa- 
rated. Through such an opening, omentum or a knuckle of intes- 
tine may be drawn into the uterine cavity. It is sometimes ad- 
vised to precede this method by the use of a tent, but it does not 
seem necessary. The dilatation can be accomplished by the bou- 
gies in shorter time than by divulsion. 

88. Incision of the Cervix. — The external os, when very rigid, 
or when the cervical canal is partly dilated by an extruding 
fibroid, may be incised. This procedure may be resorted to for 
abortion in the absence of proper dilating instruments. An 




Fig. 38. — Pratt's Dilators. 



PELVIC EXAMINATION. 



47 



incision from i centimeter to 1.5 centimeters should be made 
with scissors upon either side. As the ordinary scissors shp off, 
the Kuchenmeister scissors (Fig. 40) are more effective. The 
procedure is most readily accomplished by grasping each lip with 







Fig. 39. — The Method of Dilatation \Yith the Graduated Bougies. 

a double tenaculum and incising on either side with a knife. The 
operation completed, the incised cervix should be closed with 
sutures. 

89. Complete bilateral incision of the cervix is rarely indicated, 




Fig. 40. — Kuchenmeister's Scissors. 

as other measures of less severity can be utilized. The operation 
may be supplemented, if necessary, by ligation of the uterine 
arteries. The vessels may be secured by drawing the cervix to 
one side and passing a ligature with a strongly curved needle. 



48 GYNECOLOGY. 

Care should be exercised to keep close to the uterus and not to 
carry the ligature forward of a line tangent to the anterior cir- 
cumference of the cervix, in order to avoid ligation of the ureter. 
A second ligature is passed upon the opposite side, when the 
cervix can be incised with a knife to the vaginal fornix on either 
side without danger of hemorrhage. Although generally advised 
that ligation should precede incision, it is unnecessary. Hemor- 
rhage does not always occur, and when it does, the bleeding 
vessels can be seized with forceps and then ligated. If the finger 
can not be passed through the internal os, the canal can be still 
further enlarged with a probe-pointed bistoury. After ex- 
ploration or operative procedure the cervix should be carefully 
sutured. The lateral ligatures should be removed in two or three 
hours, or in a shorter time if there is any reason to fear that the 
ureter has been ligated. The prolonged retention of the ligatures 
would result in sloughing of the vagina. 

90. Dilatation by Gauze Packing. — VulHet has devised a pro- 
cedure for prolonged dilatation, which he denominates a ''method 
of dilatation by progressive plugging." It consists in repeated 
plugging of the cervical canal w4th medicated gauze. Strips of 
gauze, after the uterus has been carefully cleansed, are packed 
into the cervical canal until it is completely filled. These are 
permitted to remain for forty-eight hours, when they are re- 
moved, and if the uterus is not then dilated sufficiently to admit 
the finger, the cavity is again cleansed and packed. Pieces of 
compressed sponge have been used for a similar purpose, and, 
from their increase in size under moisture, are probably more 
effective. The only source of anxiety is the uncertainty as to 
their being absolutely sterile. This plan of procedure may be 
carried over a series of days or weeks, without inflammatory re- 
action. It is, however, not effective in cases of rigid cervix, 
and the same purposes may be accomplished by a more rapid 
dilatation. 

91. Microscopic Examination. — It is evident from the pre- 
ceding that careful investigation of tissue changes is often neces- 
sary to confirm, and add to, the data secured by inspection and 
touch. The microscope here proves an important diagnostic 
factor. It throws light upon obscure conditions, and affords 
opportunity for the recognition of the incipient stages of lesions 
so insidious and grave, that were the investigator deprived of the 
information it affords the accurate diagnosis would frequently 
come too late for radical treatment. Through the microscope 
the knowledge of the histologic structure of the genital organs has 
been secured, and it is apparent that it w^ould prove equally val- 
uable in betraying pathologic alterations in the course and prog- 
ress of disease. Consequently, it not only proves a valuable aid 



PELVIC EXAMINATION. 49 

in methods of diagnosis, but also upon the result of its findings 
definite ideas concerning the prognosis are based, and suitable 
methods of treatment instituted. 

92. Collection of Tissue. — Tissue collected for microscopic 
examination is procured by test curetment and test excision. 
Occasionally sufficient tissue can be expressed from the genital 
tract or escape in discharges, from which reasonably satisfactory 
microscopical examinations can be made. Generally, however, 
only small particles of tissue escape and these usually indicate the 
existence of marked degenerative changes, and, therefore, the 
tissue must necessarily be so altered by necrobiotic processes as 
to render positive microscopic diagnoses uncertain and difficult. 
Test excision is employed in cases of suspected disease in the 
loAver part of the genital tract and cervix. The test curetment is 
performed in cases of suspected disease in the interior of the cor- 
pus uteri. In certain conditions these two methods of collecting 
tissue may with distinct advantage be combined. 

93. Test Excision. — The method of collecting tissue from 
either the vagina or the cervix by test excision must be regarded 





Fig. 41. — Douche Curet. 

as a surgical operation and, therefore, the patient should be as 
carefully prepared as in preparation for a plastic operation. The 
bowel and bladder empty, the patient should be placed in the 
dorsal position upon the table, the parts thoroughly cleansed, and 
the cervix exposed by introducing Edebohls' speculum or suitable 
retractors into the vagina ; the cervix grasped with double tenac- 
ula, one upon each side or upon the anterior and posterior lip; 
gentle traction is made to fi^ the cervix nearer the vaginal orifice. 
With sharp scissors or scalpel a triangular or V-shaped piece of 
the cervix is so excised as to secure both healthy and diseased 
structure and a portion of the mucous membrane lining the cervi- 
cal canal. The wound left from the excision should be closed with 
one or two sutures of catgut. Closure of the wound is followed 
by irrigation of the parts with warm sterile salt solution, the vagi- 
nal canal is lightly packed with iodoform gauze, and a sterile peri- 
neal occlusion dressing applied. It is better, in the majority of 
cases, to employ general anesthesia for test excision, although it 
can be done bv anesthetizing the surface with a four per cent, solu- 
4 



50 GYNECOLOGY. 

tion of cocain applied on a cotton tampon. Infiltration anesthe- 
sia would permit of painless excision, but it destroys the cell 
structure and would,, consequently, be misleading. Each step of 
the procedure for test excision should be executed with the utmost 
delicacy. This can not be too strongly emphasized in order to 
avoid disturbing the architectural construction of the tissue and, 
therefore, alteration in the living histological cell picture. Un- 
fortunately, many surgeons collect tissue for investigation by the 
microscopist in so careless a manner that by the time the tissue 
reaches the pathologist's hands its structure is so changed as to 
render intelligent study almost impossible. 

The excised tissue should be washed in running water and care- 
fully inspected with the naked eye, and also with a magnifying 
glass ; by which its color, consistence, and general structure can 
be recognized and noted. During this examination the question 
can be determined as to what course shall be pursued in fixing and 
preparing it for a more complete examination. As the tissue will 
undergo marked change in this process of fixing, it is wise that a 
drawing should be made and the direction in which the future sec- 
tions are to be cut determined. Abel advises that excised por- 
tions be divided so that one part can be examined while fresh, and 
the other be prepared for finer sections. 

94. Test Curetment. — In employing the curet to secure mate- 
rial for examination the same precautions concerning antisepsis 
and thorough preparation must be observed as in doing test exci- 
sion. The operation is performed as follows : the patient under 
general anesthesia, in the dorsal position, the vulva and vaginal 
canal are thoroughly sterilized. The cervix is exposed by an 
Edebohls' speculum or suitable retractors, the anterior cervical lip 
fixed with double tenacula, the cervical and uterine canals are deli- 
cately and carefully dilated. The utmost caution should be prac- 
ticed in every step of the procedure and undue force must posi- 
tively be avoided in order to prevent injury of the tissue cells and 
distortion of the histology of the collected tissue, which would 
render microscopic examination unsatisfactory. Dilatation is 
best accomplished by Pratt's graduated dilators. By their use 
rapid and uniform dilatation is secured, with but little congestion 
or traumatism to the endometrium. Laminaria tents also serve 
excellent purpose for dilatation. Dilatation with tents should be 
done with all surgical cleanliness. One or two are introduced and 
allowed to remain for a period of twelve hours ; when, if sufficient 
dilatation is not secured, a nest, comprising three or four tents, is 
introduced and allowed to remain twelve hours more. Dilatation 
by tents has the great advantage that it permits digital explora- 
tion of the uterine cavity. This exploration, however, should 
follow the curetment, for the previous introduction of the finger 



PELVIC EXAMINATION. 



51 



would, to a certain degree, disarrange and render unsatisfactory 
the endometrium for microscopical examination. Tent dilatation 
has the disadvantage of requiring twelve to twenty-four hours for 
its performance, but this additional time is often compensated by 
the information afforded the exploring finger, because digital exam- 
ination of the uterine interior may disclose lesions which the curet 
has failed to reveal. In the employment of either of the methods 
described a high degree of dilatation should be secured. The uterus 
is cureted with a long, sharp douche curet having an acute angle. 









Fig. 42. — Tissue Removed bv Test Curetment. 



It is well to start the curetment at a fixed point, either the poste- 
rior or lateral wall, and with long successive sweeps, proceed from 
the fundus to the cervical opening, removing the membrane to the 
muscle structure. As the tissue escapes from the uterus it should 
be collected by an assistant in a sieve made of paraffin paper, (Fig. 
42.) The collection of cureted tissue on sterile gauze is to be con- 
demned, as the tissue adheres to this material, and in its removal 
the individual elements are torn and distorted. The tissue thus 
collected is examined microscopically and any peculiarities re- 
corded, after which it should be immediately transferred to a fix- 
ing solution unless frozen sections are preferred. 



52 GYNECOLOGY. 

95. Disposition of Tissue. — The injuries resulting from undue 
and careless handling of tissue after test excision or curetment has 
been previously mentioned and can not be too strongly empha- 
sized. Surgeons often fail to realize the value of avoiding careless 
manipulation of the specimens and frequently unwittingly destroy 
the living cell construction by prolonged exposure of the specimen 
to the air and to injudicious handling. The advantages of imme- 
diately fixing the tissue after removal are many. The wrapping 
of any specimen or specimens in gauze, as already mentioned, is to 
be positively condemned. Tissue so treated soon dries, the gauze 
becomes firmly adherent to it, and in its removal tears and disar- 
ranges the surface cells. In case the fixative agent is not at hand, 
cureted or excised tissue can, without harm or injury, be tempo- 
rarily placed in paraffin paper, although it is decidedly advan- 
tageous to have fixative agents prepared and ready for the recep- 
tion of the material prior to its removal. By such means the 
individual cell elements are permanently fixed as they occur in 
life, and the microscopist is thus enabled to satisfactorily study 
the cell chemistry and general cell construction of the specimens. 
After the specimens are placed in fixative agents the vehicle con- 
taining them should be numbered and properly labeled. The 
label should contain the name of the patient, her age, the date of 
operation, the character of the operation, the part from which the 
tissue is obtained, together with a brief history. 

96. Examination.— The specimens may be examined as teased 
specimens, or be cut with the freezing microtome. The latter 
course is preferable, as it interferes less with the relations of the 
structures, and, consequenth^ permits a more correct judgment 
as to the condition. 

By teasing, the elements are separated from each other when 
it is impossible to decide whether the surface epithelium sends 
processes into the tissues or whether a simple hyperplastic or 
destructive process exists — points of the greatest importance in 
arriving at a correct diagnosis. 

The fresh specimen should be cut with the freezing microtome, 
but the sections should not be too thin, as they are likely to 
tear in subsequent manipulation. 

, Each section is removed from the knife with a camel' s-hair 
brush and placed in distilled water. To prevent the sections from 
being torn in transmission to the slide, it is better that the latter 
be pushed under the section as it swims in the fluid and be gently 
held with a glass rod. 

The section, having been carefully spread upon the slide, is 
then covered with a fine cover-glass. The latter is grasped at one 
edge with forceps, the other side brought at an acute angle upon 
the fluid covering the surface of the slide and gently released, re- 



PELVIC EXAMINATION. 53 

moving the superfluous fluid with blotting-paper. The section 
can now be studied with high or low power, but when unstained is 
best placed upon a dark under layer. 

Specimens so studied have the advantage that we see the cells 
as they were during life, and the character of the normal tissue 
or any degenerative process can thus be recognized. 

The specimen may be subjected to various microchemical 
reactions which will afford valuable information. The section 
may be rendered more transparent by a drop of a 2 or 3 per cent, 
solution of acetic acid placed under the edge of the cover-glass. 
A piece of blotting-paper held at the other side causes it to 
penetrate the section quickly. Fatty tissues may be removed 
by the similar use of alcohol, chloroform, or ether. 

Elastic fibers are rendered prominent by caustic soda in a 
I to 3 per cent, solution. A marked swelling of the contractile 
elements of the smooth and striated muscles and of the nuclei 
occurs, and the horn}^ substance becomes transparent. A ;^^ 
per cent, solution of caustic potash is especially valuable as a 
preservative. Red blood-cells preserve their form well in such a 
solution. 

Infarctions or plethora of blood-vessels are in no way so well 
observed as in fresh specimens. They may be permanently pre- 
served by replacing the salt solution with glycerin, or preferably 
with a 55 per cent, solution of potassium acetate. Pick's method 
presents the best procedure for preserving frozen specimens, and 
consists in the use of alum-carmin combined with formalin. 

The alum-carmin of Grenach (4 to 5 per cent, of carmin) is 
added to Schering's formalin 10 to 100, which should be kept in 
a dark-colored bottle. 

Pick's process is as follows: 

1. Preparation of the frozen section with Jung's microtome. 

2. Transference of the section into a 4 per cent, formalin 
solution for one-fourth minute. 

3. Formalin-alum-carmin, two to three minutes. 

4. Washing in water, one-half minute. 

5. Eighty per cent, alcohol, one-half minute. 

6. Absolute alcohol, ten seconds. 

7. Carbol-xylol, one-half minute. 

8. Canada balsam. 

Coplin says that his experience convinces him of the necessity 
for thoroughly fixing all tissues before attempting to section 
them, otherwise the results are always open to criticism, because 
the distortion incident to congelation masses; maceration; and 
the difficulty of removing the infiltrates produce conditions which 
would mislead the most experienced observer. He advises the 
following fluids : 



54 GYNECOLOGY. 

1. Flemming's solution, which consists of a i per cent, aqueous 
solution of chromic acid, 25 volumes; i per cent, aqueous solution 
of osmic acid, 10 volumes; i per cent, aqueous solution of acetic 
acid, 10 volumes; water, 55 volumes. 

All water in stock solutions and final mixtures must be dis- 
tilled. Small pieces (five-tenths — i cm. cube) will undergo 
sufficient fixation in from one-half to two hours. After this 
process is complete they should be w^ashed in running water for 
six hours. 

2. Hermann's solution: i per cent, aqueous solution of platinic 
chlorid, 15 volumes; 2 per cent, aqueous solution of osmic acid, 
2 volumes; glacial acetic acid, i volume. 

3. He regards corrosive sublimate solution as the most useful 
fixing agent for general use, although for pure cell study the first 
two solutions are probably better. It consists of 125 gm. of 
corrosive sublimate dissolved in a liter of 0.5 per cent, solution 
of sodium chlorid in water. Small pieces fix in this solution in 
from one-half to two hours. The used solution is filtered back 
into the stock solution, while the hardened tissue is washed in 
water, or preferably in 70 per cent, alcohol. This solution is of 
advantage because of its cheapness, keeping qualities, and 
simplicity of technique. 

In the process of fixing with any of the plans, the quantity 
of fluid should several times exceed the volume of tissue to be 
fixed. 

It is important for purposes of diagnosis that the tissues 
should not only be properly fixed, but that sections should be 
made with as little disturbance of cell relation as possible. At- 
tention must also be given as to the direction in which sections 
shall be made through the tissues. Sections parallel with the 
surface of a mucous membrane are of but little value, as they cut 
across glands and afford no indication of the true character of 
epithelium. The most serviceable are the vertical or slightly 
oblique. 

Embedding. — A small piece of tissue may be prepared for 
section-cutting by being embedded in either gelatin, celloidin, or 
paraffin. 

Glycerin-gelatin. — Ten grams of the finest gelatin are placed 
in a clean vessel and covered with water. After four to six 
hours the water is poured off, and the mass liquefied by a mod- 
erate heat. While stirring with a glass rod, ten grams of glycerin 
and five drops of carbolic acid are added, and the mixture left 
in a wide-mouthed bottle. To embed a specimen, a piece of 
this mass is taken and liquefied by heat. A thin layer is poured 
upon the surface of a cork, the specimen placed upon it, and then 
covered with a mantle of gelatin which soon becomes hard. 



PELVIC EXAMINATION. 55 

After being immersed in absolute alcohol for twenty-four 
hours good sections can be made. 

Celloidin. — The specimen is placed for twenty-four hours in 
absolute alcohol, and the same length of time in sulphuric ether. 
It then remains twenty-four hours in a tight bottle containing 
thin celloidin. At the end of this period it is placed in a thick 
solution, a small opening being left so that the alcohol and ether 
evaporate very slowly. In a few hours a semi-solid mass has 
formed, a block of which containing the specimen is cut out, 
fastened with thick celloidin upon cork or wood, after which 
it remains for twelve hours in a 70 to 80 per cent, solution of 
alcohol, when it has the proper consistence for section-cutting. 

Paraffin. — Abel prefers to stain the specimen preparatory to 
embedding in paraffin. The specimen, hardened in alcohol, is 
placed in the staining solution. This may be Bohmer's hem- 
atoxylin, eosin, or safranin. It should remain in a well-filtered 
solution two to eight days, according to its thickness. It is 
removed from the staining solution to 70 per cent, alcohol for 
twenty-four hours, then is dehydrated in absolute alcohol. It is 
placed in xylol for twelve hours to prepare it for saturation with 
paraffin. The specimen is placed in a mixture of equal parts of 
xylol and parafhn, in which it remains for twenty-four hours, 
subjected to a continuous temperature of 37° C. in a paraffin 
oven, after which it is kept in paraffin at a temperature of 48° 
to 50° C. The latter is then permitted to solidify at the room- 
temperature, when a paraffin block of suitable size containing the 
specimen is cut out and fastened to a cork or a piece of w^ood with 
paraffin, after which it is ready for cutting. 

The sections thus secured are thinner than those secured by 
any other method. 

Section-cutting. — Sections are preferably cut with a microtome 
and should be of equal thickness. A thickness of fifteen to 
twenty microns will be satisfactory. 

The sections are conveyed with a camel's-hair brush to a basin 
containing dilute or absolute alcohol; the celloidin sections to 
a 70 per cent, solution of alcohol, the gelatin sections to absolute 
alcohol. The sections are very much shriveled by the alcohol 
and should be placed in water for several minutes before being 
transferred to the staining fluid. 

The paraffin sections can not be transferred from one vessel 
to another; it is better to treat them on the slide. Abel applies 
one drop of a solution of collodion in alcohol upon a slide, and 
upon this the section, pressing it down with filter-paper. The 
paraffin is dissolved out with xylol, and covered with equal parts 
of xylol and Canada balsam, and over this the cover-glass is 
carefully placed. 



56 GYNECOLOGY. 

Staining. — We will consider only those methods which are 
most effective in rendering prominent the histologic structures we 
are desirous of utilizing in the diagnosis. Picrolithiocarmin and 
hematoxylin are both very satisfactory. 

The picrolithiocarmin, introduced by Orth, is prepared by 
uniting one part of lithiocarmin (a cold saturated solution of 
lithium carbonate in which carmin powder has been dissolved in 
the proportion of 2.5 grams of the latter to 100 grams of the for- 
mer solution) with two parts of a saturated solution of picric 
acid. This stain is best suitable for specimens which have been 
hardened with alcohol. The section is placed in the staining 
solution by a spatula and remains five to ten minutes, from which 
it is conveyed for one to two minutes to a solution of alcohol 
(70 per cent.) one hundred parts, hydrochloric acid one part, then 
washed in dilute alcohol and dehydrated in absolute alcohol. 
The specimen is made clearer by oil of cloves, oil of bergamot, or 
xylol. It is conveyed to the shde and spread out free of folds. 
It is then mounted in Canada balsam. Horny cells, fibrin, 
hyaline substances, and red blood-corpuscles take on a yellow 
color. The nuclei of the epithelium become a pale pink, fibrillar 
tissue remains undyed, affording a clear picture of the specimen 
stained. Hematoxylin stain is prepared by Coplin after Delafield 
as follows: Dissolve 4 gm. of hematoxylin crystals in 25 c.c. of 
strong alcohol; add this solution to 400 c.c. of a cold, filtered, sat- 
urated aqueous solution of ammonia alum; expose to light and 
air for several days. Filter and add glycerin 100 c.c. and methyl 
alcohol 100 c.c. This preparation is allowed to stand in the light, 
with the bottle loosely corked ; this mixture turns dark purple or 
almost black. i\fter assuming this color it should be filtered and 
placed in tightly stoppered bottles. Before being used it should be 
largely diluted, and if properly prepared this stain will last for 
years. The great objection to Delafield 's mixture is that it re- 
quires time for ripening and therefore can not be used immediately 
after being made. Harris has overcome this objection by prepar- 
ing the mixture as follows: Dissolve i gm. of hematoxylin in 
10 c.c. of alcohol and add the resulting solution to 200 c.c. of dis- 
tilled water in which 20 gm. of ammonia or potassium alum have 
previously been dissolved. This fluid is heated in a flask to boil- 
ing, at Avhich time i gm. of mercuric acid is added. The solution 
darkens (ripens) at once and is now ready for use, but should 
always be diluted. From this stock solution an acid hematoxylin 
may be prepared by adding 4 c.c. of glacial acetic acid and 30 c.c. 
of glycerin to 70 c.c. to the primary solution. This acid prepara- 
tion has the great advantage of rendering overstaining almost 
impossible. 

Hematoxylin Staining. — To use the hematoxylin stain of Dela- 



PELVIC EXAMINATION. 57 

field or Harris the sections cemented to the slides are covered with 
the diluted stain from five to fifteen minutes. They are then 
washed in water, dehydrated in alcohol, cleared with creasote, and 
mounted in Canada balsam. Coplin states that a better result is 
obtained by placing enough distilled water in a staining dish to 
immerse the slide on end, to this sufficient hematoxylin is added 
to tinge the water rather deeply. The sections adherent to the 
slides are permitted to remain in this solution twelve to twenty- 
four hours. They are then cleansed in water and treated as di- 
rected previously. Hematoxylin stains the nucleus purple and 
gives a faint tint to the protoplasm shapes. Definition of the pro- 
toplasm can be secured by following the hematoxylin staining by 
placing the slides and section in an 0.5 alcoholic solution of eosin 
for one or two minutes. The excess of water is removed and sec- 
tion washed in alcohol, cleared in creasote, and mounted in balsam. 
This method stains the nuclei purple and the surrounding proto- 
plasm pinkish, besides, the eosin stains the erythroc^^tes pres- 
ent. One of the very best contrast stains is that suggested by 
Van Geison, which is composed of the following : 

Acid fuchsin (i per cent, aqueous solution), 15 c.c. 

Picric acid (saturated solution), 50 c.c. 

Water, 50 c.c. 

In using this stain the sections are first stained with hematoxy- 
lin, washed in water, followed by applying the Van Geison stain 
for four or five minutes, dehydrated in alcohol, cleared in xylol, 
and mounted in xylol balsam. By this method the connective 
tissue appears red or pinkish red, the cell protoplasm yellow, the 
nuclei dark brownish or reddish purple. 

Hematoxylin stain is prepared by dissolving i gram of 
hematoxylin in 30 grams of absolute alcohol. To a solution of 
powdered alum (0.5 to i gram in distilled water 30 cm.) the above 
preparation is added drop by drop and shaken until the fluid 
takes a deep violet color. 

Celloidin-embedded sections remain longer (ten to twenty 
minutes, according to size and thickness) in the solution than 
sections prepared by other methods, and are placed in alcohol con- 
taining hydrochloric acid until they begin to assume a red tint, 
from which the}^ are removed to 70 per cent, alcohol. They are 
placed in absolute alcohol until the mantle of celloidin begins to 
curl. Care must be exercised that all the celloidin is not dissolved 
or the finer sections would fall to pieces. The section is made 
transparent in oil of bergamot or in xylol. Should the celloidin 
mantle at this stage become cloudy or milky, the section should 
be placed in absolute alcohol until it clears. With a spatula the 
section is placed upon a shde and mounted in xylol-Canada 
balsam after removing the oil with filter-paper. This method 



58 GYNECOLOGY. 

gives ^Splendid staining of the nuclei, the protoplasm is slightly 
stained, the celloidin not at all. The diagnosis of malignant 
conditions is greatly enhanced by staining the elastic fibers. 
For this purpose Taenzer's orcein stain is employed. The 
sections are taken from water and kept' in this solution from six 
to twelve hours or longer (Griibler's orcein 0.5, alcohol 40.0, aq. 
dest. 20.0, hydrochloric acid gtt. xx) , then placed for a few seconds 
in hydrochloric acid alcohol (hydrochloric acid o.i, 95 per cent, 
alcohol 20.0, aq. dest. 5.0), where they become differentiated and 
are washed in water. After five to ten minutes' dehydration in 
absolute alcohol, they are cleared in oil and mounted in Canada 
balsam. 

The elastic fibers appear as an intense red upon a pale pink 
background. 

Weif^ert's fuchsin-resorcin stain is made by taking 200 c.c. of 
the following mixture: Resorcin 2.0, fuchsin i.o, distilled water 
1 00.0, and bringing it to a boil in a porcelain vessel, when 25 c.c. 
ferri liq. sesquichlor. (German Pharmacopeia) are added, the 
whole boiled while stirring for two to five minutes longer. The 
muddy mass thus formed is permitted to cool and then filtered. 
The portion which runs through the filter is thrown away, and 
the deposit left upon the filter until it ceases to drip. 

The filter with its contents is removed from the funnel, 
placed in a bowl, and boiled under constant stirring with 200 c.c. of 
94 per cent, alcohol. While boiling the filter-paper is removed 
and the solution is permitted to cool, after which it is filtered and 
the filtrate brought to 200 c.c. by the addition of alcohol. After 
adding 4 c.c. of hydrochloric acid the solution is ready for use. 

The sections are placed in this solution for twenty minutes 
to one hour, washed in alcohol, and cleared in xylol. 

The elastic fibers are stained dark blue, almost black, on a 
quite light background. The nuclei may be stained with a 
carmin preparation. 

97. Preservation of Gross Specimens and Slides. — In order to 
keep a complete case record it should be the rule to preserve the 
gross specimens and slides containing sections therefrom. Many 
agents have been recommended for the preservation of gross 
specimens. Alcohol is perhaps the reagent most commonly em- 
ployed, but by its use the density of the specimens is altered, the 
color entirely lost, and general outline indifferently retained. For- 
malin has recently gained considerable prominence as a valuable 
preservative. A ten per cent, solution of the commercial prepara- 
tion is usually employed. Specimens prepared by this method 
can be used with a higher degree of satisfaction for histologic 
study than those prepared with alcohol. Specimens when not 
too large can also be preserved in formalin vapor by placing them 



PELVIC EXAMINATION. 



59 



in an air tight jar containing a bed of cotton which has been pre- 
viously moistened with pure formaHn. The specimen should be 
placed upon the cotton and covered with filter-paper moistened 
with the reagent. For the retention of the color of gross speci- 
mens no method possesses such advantages as those afforded by 
the use of Kaiserling's solution. Two solutions are necessary and 
are composed of the following : 

Solution A. 

Formalin 250 c.c. 

Nitrate of potassium, 10 gm. 

Acetate of potassium 30 gm. 

Water, i liter. 

SOLUTIOX B. 

Acetate of potassium 200 gm. 

Glycerin, 400 c.c. 

Water , 2000 c.c. 

Formalin, to point of saturation. 

The specimen prior to being placed in the preservative is 
lightly washed with running water to remove adhering blood and 
is then placed, according to size, from one to twenty-four hours in 
Solution A, at the end of which period it is changed to a fresh 
Solution A, in which it is allowed to remain from two to thirty-six 
hours. It is then w^ashed in 
running water from fifteen min- 
utes to one hour and placed in 
eighty per cent, alcohol in order 
to cause a reappearance of the 
color. Unless the color shows 
signs of returning the specimen 
is transferred to ninety-five per 
cent, alcohol, in which it is 
allowed to remain until the color 
is fully restored. After the color 
is thus restored the specimen is 
placed in Solution B and at the 
end of twenty-four to forty- 
eight hours it should be placed 
in a fresh portion of Solution B. 

In preserA^ation of slides the 
best results are obtained by using 

a card index system. Special histologic or slide cases are made 
containing trays for the slides and also a card index as shown in 
Fig. 43. By using this method the slide is labelled and numbered 
and the number corresponds to the number on the index card 
which contains the name of the" patient, her age, date of occupa- 
tion, name of organ from which tissue was removed, and patho- 




Fig. 43. — Cabinet with Trays and 
Card Index for the Preservation 
of Slides. 



60 



GYNECOLOGY. 



logic diagnosis. An ingenious slide card index has been devised 

by Coplin. (Figs. 44 
and 45.) The slides 
are properly labeled 
and numbered and 
then placed in the 
card and secured by 
sealing the free end 
of the card paper. 
The index card is 
marked in the same 
manner as that de- 
scribed above. The 
cards containing the 
slide are preserved in 
dust proof drawers. 
This method offers 
the advantage that 
the slide can not be 
separated from the 
name of the patient, 
and from its ingeni- 
ous arrangement 
can be submitted to 
microscopic exami- 
nation without re- 
moval from the card . 

98. Failure. — Examination may fail to reveal the true 
character or presence of disease, because the section was made 
through the adjoin- 
ing healthy tissue. 
The examination 
may also prove un- 
satisfactory and 
worthless as a result 
of mutilation and 
distortion of the 
specimen incident to 
undue manipulation 
and carelessness in 
collection and from 
improper technique 
in preparation for 
study. 

99. Bacteriology of the Genital Tract.^ — The importance of 
careful bacteriologic examinations of the secretions of the geni- 




Fic 



44- 



-Coplin's Method of Indexing and Preserv- 
ing Slides. 



m. 473, 



MRS. 3. R. 



VATH. 



JULY 10^i90e. 
• TISSUE FBOM UTERINE BODY. 
DIAG. HYPERTROPHIC GLAHOUIAR ENDOMETRITIS. 




Fig. 45. — Same as Fig. 44. Folded with Slide En- 
closed. 



PELVIC EXAMINATION. 61 

tal tract can not be overestimated. Careful bacteriologic an- 
alyses of the genital secretions not only increases the clinical in- 
terest of a case, or special cases, but stimulates scientific re- 
search, and, therefore, renders the case records complete and 
more worthy of preservation. Furthermore, scientific bac- 
teriologic examinations of the secretions of the genital tract 
will enable us to diagnose definitely the provocative factor 
in conditions which might otherwise remain obscure. We 
are also enabled to determine the specificity, sterility or viru- 
lence of infiammatory accumulations and thus become better 
qualified to advise and institute proper methods of treatment 
and interpret, to a certain degree, the probable outcome of a 
given case. 

100. Parasites of the Genital Tract. — Parasites, both of animal 
and vegetable origin, as in all other cavities of the body, are found 
in the genital tract. Of course, here, as elsewhere in the body, 
bacteria or vegetable parasites preponderate and are the most 
provocative of harm. In health, micro-organisms inhabiting 
the genital canal are limited to the structures of the vulva and 
the vaginal canal. Furthermore, even in this part of the geni- 
talia, they are found in minimum numbers and attenuated in 
virulence. The special organism cultivated and described by 
Doderlein is found more or less constant in the vaginal canal 
and has been termed the acid vaginal bacillus of Doderlein. 
It is said to generate lactic acid and is a rod-shaped bacillus of 
the anaerobic type whose discoverer believes it to be a protective 
force against the invasion and action of pathogenic germs. 
He further believes that even if pathogenic bacteria gain 
entrance to the vagina their virulence is attenuated by the 
presence of this germ. This micro-organism flourishes in the 
normal acid secretion of the vagina, and if the acidity of the 
vaginal secretion is destroyed it disappears and other bacteria 
enter. It has been demonstrated by Stroganoff that micro- 
organisms are more numerous in the vagina preceding and 
following menstruation. It has been discovered that the in- 
fectious properties of bacteria are diminished as they ascend 
the vaginal canal and approach the cervix. In the newborn 
the vaginal canal is entirely bacteria free, but soon after birth 
their presence can be demonstrated. In the normal individual, 
according to Kronig, ]\Ienge, and Whitridge Williams, it is not 
possible for bacteria to exist long in the healthy vaginal secre- 
tion. Kronig demonstrated the germicidal action of vaginal 
secretion by introducing various organisms into the vagina of 
a normal individual. At the end of two days the vagina be- 
came entirely bacteria free. Streptococci were the first to suc- 
cumb, staphylococci and pyocyanei living twice as long. Dur- 



62 GYNECOLOGY. 

ing pregnancy it is asserted that the acidity of the vaginal secre- 
tion is increased and that bacteria are not present. WilHams, 
in ninety-two pregnant women, found the skin staphylococcus 
twice, never the streptococcus. Kronig, in forty-eight pregnant 
women, did not find any. From extensive observations it is 
asserted, therefore, that pyogenic bacteria, when found in the 
puerperal genital tract, have been introduced from without. 
From a bacteriologic standpoint the healthy genital canal can 
be separated into three portions: the inferior portion, com- 
prising the vulva and vagina to the cervix, containing bacteria; 
the middle comprises the cervical canal between the external 
and internal os and, as a rule, is free from bacteria. The remain- 
ing portion is formed by the uterus, tubes, and ovaries and is 
entirely free from germs. Alenge, in his investigations of uteri 
removed in Zweifel's clinic, was not able to cultivate germs on 
any ordinary culture media. The external os can then be 
said to be the boundary line between that part of the genital 
tract containing micro-organisms (vulva and vagina) and the 
part bacteria free (uterus, tubes, and ovaries). The vulva and 
the vaginal canal always contain bacteria, and Edgar found in 
twenty-eight pregnant w^omen and two parturient women pyo- 
genic bacteria present in forty per cent. 

loi. Natural Agents of Immunity. — It has been demonstrated 
that parasites of many varieties, both animal and vegetable, 
are found more or less constantly in the lower portion of the 
genital canal in the normal healthy woman. They are present, 
however, only in small numbers and with attenuated speci- 
ficity. This is because Nature provides natural agents for 
protection or securing immunity. .The protective powers of 
the normal genital canal are found, i, the acid secretion of the 
vagina which is decidedly inimical to pathogenic bacteria; 2, 
the dense arrangement and phagocytic action of the wall of 
stratified epithelium lining the vagina is also hostile to invading 
micro-organisms; 3, the plug of coagulated secretion commonly 
found in the os externum, while not truly germicidal, does act 
as a barrier against the entrance of germs into the uterine cavity 
and structures above. The restraining and destructive influ- 
ence exerted by the bacillus of Doderlein against invading 
pathogenic bacteria has been mentioned. 

It may, therefore, be asserted that so long as the vaginal 
epithelium remains healthy and intact, the natural secretions 
normally generated and the vaginal bacilli present, pathogenic 
bacteria may be found, but their excessive production is in- 
hibited and their destructive influence allayed. 

102. Loss of Protection. — Certain conditions alter the normal 
acid secretion of the vagina, rid the canal of its protective micro- 



PELVIC EXAMINATION. . 63 

organisms, and change the epithelial wall and permit thereby 
the proliferation of infectious micro-organisms and the generation 
of their poisons. Traumatisms produced by manipulation, 
indelicate examinations, raw surfaces left by operation, and in- 
juries resulting from labor afford gateways for the introduction 
of infectious germs into the absorbing tissue tracts. The natural 
bacterial secretion of the vagina is rendered neutral or alkaline 
or wholly destroyed by increase of discharges from above, such 
as takes place during menstruation, during parturition, and in 
alterations of general health. Repeated examinations and per- 
sistent douching also destroy the antiseptic properties of the 
vaginal canal. 

103. Parasites. — I have already indicated that parasites of 
all varieties, both animal and vegetable, are found in the genital 
tract. I stated that the vegetable were, of course, the most 
frequent and most powerful for harm. The following table 
shows the varieties of parasites most frequently found : 

Vegetable (Bacteria). 

Staphylococcus pyogenes aureus Smegma bacillus. 
Staphylococcus pyogenes albus 

Streptococcus pyogenes. Bacillus typhosus. 

Staphylococcus pyogenes. Bacillus pyocyaneus. 

Gonococcus. Bacillus aerogenes capsulatus. 

Bacillus coli communis. Bacillus diphtheria. 

Bacillus tuberculosis. Pneumococcus. 

Organism of syphihs. Diplococcus of Siegelman. 
Organism of chancroid. 

Animal. 

Pediculosis pubis. Ascaris lumbricoides. 

Ascaris scabiei. Taenia echinococcus. 

Oxyuris vermicularis. 

104. Staphylococcus. — The staphylococcus pyogenes aureus is 
perhaps the micro-organism most commonly found in localized 
suppurative processes, and, according to Coplin, Curry found it 
present in fifty-two of one hundred and fifteen abscesses. The 
staphylococcus pyogenes albus was present in twenty-nine. (Fig. 
46.) The tendency of the staphylococcus is to cause local sup- 
purative lesions, although it may produce general pyemic infec- 
tion and fatal septicemia. I recall one case of fatal staphylococ- 
cemia in which pure cultures of staphylococci were found in the 
blood following a plastic operation on the perineum and cervix. 
This germ is found singly, in pairs, in fours, and in short chains, 
but generally in irregular clusters or grape-like bunches. It grows 
in all ordinary culture media at a temperature between 20° C. and 
40° C. It rapidly liquefies gelatin and in the process of growth the 
colonies fall to the bottom of the medium, assuming a bright 
orange yellow color, hence its name. The culture colonies are at 



64 



GYNECOLOGY. 



first small and of a white hue, but by the third day they assume 
the characteristic golden yelloAv or orange color. The staphylo- 
coccus stains by all the common anilin dyes, but does not respond 
to Gram's method. The staphylococcus and its kin are perhaps 
the most frequent cause of local inflammation and suppuration of 
the uterus and its appendages and of the pelvic peritoneum. A 
special feature of this germ is its strong attractive chemotactic 
influence upon leukocytes, particularly the polynuclear cell. In 
two thousand and ninety-eight cases of purulent salpingitis three 
hundred and seventy-four were found to be due to puerperal sep- 
tic infection, mostly of staphylococcic origin. 

105. Streptococcus. — The streptococcus pyogenes generally 
occurs in chains. It is the most virulent of all the pyogenic cocci 
and measures one-half to one micron in diameter. (Fig. 47.) It 
grows well at a temperature of from 30° C. to 40° C, but does not 




Fig. 46. — Staphylococcus Pyogenes 
Aureus. From Pure Culture in 
Bouillon. (Zeiss, 2 mm., Oc. c.) 




47. — Streptococcus Pyogenes. 
From Culture in Bouillon. 
(Zeiss, 2 mm. Obj., Oc. c.) 



grow readily below 20° C. and is killed in ten minutes at 5 2° C. It 
groAvs on all common culture media, appearing as small elevated 
circular colonies of a grayish-white color. It does not liquefy gel- 
atin. The streptococcus stains with the common anilin dyes 
and is positive to Gram's method. This germ is found in spreatl- 
ing inflammatory processes, with or without suppuration, in 
serious phlegmonous and erysipelatous conditions and suppura- 
tions, in serious membranes and joints. Streptococci are also 
found in malignant endocarditis and suppurative periostitis. 
They are found in inflammatory disease of the mucous membrane, 
particularly the mucous membrane of the throat, where they 
cause a pseudo-diphtheritic inflammation. In puerperal perito- 
nitis they are found in a condition of purity, and this organism is 
undoubtedly the most frequent cause of puerperal septicemia. 
The streptococcus is less local in its action and far more virulent 



PELVIC EXAMINATION. 



65 



than the staphylococcus. In septic peritonitis and puerperal 
septicemia the organism is easily conveyed to the vaginal canal or 
uterus from without, and it is transported from the vagina or the 
uterus to the pelvic peritoneum through the lymph channels, 
blood-vessels, and by penetration of the uterine wall. The late 
Dr. Pryor asserted that the passage of this germ through the 
uterine wall should be counted by hours and not days. Sections 
of puerperal septic uteri demonstrate that Dr. Pryor was not in- 
correct in this assertion, for in nearly all cases the organism can be 
recognized microscopically throughout the tissues of the uterus. 
Doderlein, in his investigations of the vaginal secretions of nearly 
two hundred women, found only one-half normal. The remainder 
were bacteriologically abnormal. In ten per cent, of the normal 




Fig. 48. — Secretion from Gonorrheal Vaginitis, Showing the Gonococci Both 
Within and Without the Pus-cells. 



a, Pus-cell Containing Gonococci; b, Pus-cell Undergoing Dissolution; c, 

EpitheHal Cell. 



Large 



cases the streptococcus pyogenes was present, and inoculations 
with the secretions from fifty per cent, of these revealed that 
they were pathogenic for animals. Secondary abscesses in the 
lymphatic glands are more frequently caused by streptococci 
than by staphylococci. The virulence of the streptococci varies. 
106. Gonococcus. — The gonococcus was first described by 
Neisser in 1879, and later cultivated in solidified serum by Bumm 
and others. It has been definitely determined to be the specific 
cause of gonorrhea. The gonococcus under the microscope re- 
sembles in appearance two coffee-beans placed side by side, with 
an unstained oval interval. Sternberg applied the term * ' biscmt- 
shaped" coccus. (Fig. 48.) Irregular and degenerative forms of 
the germ are, however, seen. This germ is sometimes difficult to 
5 



66 GYNECOLOGY. 

cultivate on artificial culture media. (Fig. 48.) It grows slowly 
on human blood serum or acid urine agar and blood-smeared agar 
or on Wertheim's media, appearing, at the end of twenty-four or 
forty-eight hours after inoculation, as small, irregular, rounded 
colonies of a grayish-yellow color. The margins of the colonies 
are undulated and sometimes show small projections. Colonies 
vary in size and tend to remain separate. They reach their maxi- 
mum size on the fourth or fifth day, and, according to Muir and 
jRitchie, on the ninth day or earlier die. The germ stains readily 
with the basic anilin dyes, but does not stain by Gram's method. 
The gonococcus is found in large numbers in pus of acute gonor- 
rhea, both in the male and female. It, for the most part, is con- 
tained within the leukocytes. In the earlier stages it is also found 




Fig. 49. — Secretion of Simple Vaginitis, Showing Various Forms of Organisms 

Found and Preponderance of Epithelial Cells. 

a, Bacilli; b, Streptococci; c, Staphylococci; d, Pus-cell. 

outside the pus-cells, but when the discharge is wholly purulent 
the greater portion are found within the pus-cells. Gonococci are 
also found in purulent secretion of gonorrheal ophthalmia and 
throughout the genital tract when these organs are the seat of 
Neisserian infection. The tendency of the organism is usually to 
remain and cause local genital lesions. It is not alone responsible 
for disseminated genital infections, but is also responsible for 
generalized or systemic lesions, and has been found in pure 
culture in the blood. Gonococcemia usually results from infec- 
tions of the genito-urinary organs, but cases have been recorded 
where blood infection has occurred from gonorrheal ophthalmia. 
Cases of endocarditis, endarteritis, suppurative arthritis, and gen- 
eral pyemia have resulted from the absorption of the organism. 
The gonococcus is, unfortunately, found present to an alarming 



PELVIC EXAMIXATIOX. 67 

degree, and in the female is undoubtedly the most destructive of 
all the pyogenic cocci, and when once implanted on the mucosa of 
the female genital tract, is rarely, if ever, eradicated. Sanger, in a 
series of nineteen hundred and thirty cases, reports two hundred 
and thirty suffering from gonorrheal infection. A committee ap- 
pointed by the American ]\Iedical Association found that in pelvic 
disorders of women requiring surgical interference forty per cent, 
were of the specific diplococcus origin. In the gynecological 
wards of Jefferson ]\Iedical College Hospital one in five or twenty 
per cent, of operations are performed for lesions resulting from the 
action of the gonococcus. Andrews, discussing the etiology of 
salpingitis from a series of statistics collected from twenty-eight 
sources, shows that in six hundred and eighty-two suppurative 
tubes the gonococcus was found present one hundred and fifty- 
five times in three hundred and eight cases in which micro-organ- 
isms were demonstrated. In three hundred and seventy-four the 
pus was sterile, and he believed that many of these were primarily 
of gonorrheal origin. Kleinhaus, in two hundred and eighteen 
pus tubes, found the gonococcus present seventy-four times. The 
large number of sterile tubes found was explained by the fact that 
the gonococcus disappears early from pus, and it is, moreover, 
extremely difficult to demonstrate the micro-organism in the tubal 
wall. The gonococcus, however, does not always disappear from 
the contents of the pus tubes early, because cases have been re- 
ported of old-standing pus tubes being operated upon, followed 
by suppurative peritonitis in which pure cultures of gonococci 
were obtained. The gonococcus, while violent and destructive in 
action, is perhaps the most prolific cause of chronically invalided 
women and also the causative factor in destroying the structure 
of the uterine mucous membrane, rendering it unfit for lodgment, 
maintenance, and successful maturation of a fertilized ovum. 
It is also productive of great harm in the appendages of the uterus 
— the tubes and ovaries — working such changes in these organs as 
to demand their total sacrifice or cause such structural alterations 
as to prevent the proper performance of their especial functions. 
Despite the virulent influence which the gonococcus exerts upon 
the generative organs of women, it, however, rarely causes death. 
It is frequently responsible for violent attacks of peritonitis with 
alarming symptoms, but the inflammatory changes usually re- 
main localized and do not spread as infections of this membrane 
do when caused by the staphylococcus, or more particularly, the 
streptococcus. This is due to the fact that gonococci find a 
natural habitat and favorable nutrition in the cells and fluids of 
the mucous membrane lining the genital tract, particularly the 
cer\'ix and Fallopian tubes, whereas the endothelial cells of the 
peritoneum and the peritoneal fluid are, to a certain degree, hostile 



68 



GYNECOLOGY. 



and phagocytic to the gonococci, thus destroying many and driv- 
ing others into a localized field of battle. 

107. Bacillus Coli Communis. — This organism is found 
present normally in the intestinal canal. It is very similar, 
morphologically, to the typhoid bacillus. The colon bacillus is 
usually found in mixed infections, though pure infections by this 
organism do occur. Andrews, in his bacteriologic statistic 
study of pus tubes, found that the colon bacillus was present 
in 2.5 per cent. (Fig. 50.) This germ is frequently respon- 
sible for inflammatory disorders of the intestinal canal and sup- 
purative processes in the peritoneal cavity. It is often found in 
inflammation of the urinary passage, such as cystitis, pyelitis, 
and pyelonephrosis. Colon suppuration of the organs in the 
pelvis does occur, and Reed says that it is responsible for a cer- 




50. — Bacillus Coli Communis. 
From. Pure Culture in Bouillon. 
(Zeiss, 2 mm. Obj., Oc. c.) 




Fig. 51. — Bacillus Tuberculosis. 
(Zeiss, 2 mm., Oc. c.) 



tain percentage of cases of ovarian abscess. He claims that the 
diseased organ as it becomes adherent to the bowel affords an 
opportunity by the contiguous surface for the introduction of 
the germ. Roberts states that suppuration of ovarian cysts, 
especially after twisting of the pedicle and the resulting adhesions 
to the bowel, has a similar explanation, and many suppurative 
infections of the abdominal incision can be traced to this germ. 

108. Bacillus tuberculosis, discovered by Koch in 1882, is a 
rod-shaped bacillus, one and one-half to three and one-half microns 
long, one -fourth to one-half micron thick. It grows readily upon 
solidified blood sertim and glycerin agar. It develops slowly — 
does not appear for two or three weeks after inoculation. (Fig. 
51.) The colonies are of a creamish color and somewhat granu- 
lar. This becomes more marked as the growth ages, and, accord- 
ing to Coplin, the surface of the colony takes on a bread-crumb 



PELVIC EXAMINATION. 69 

appearance. The bacillus stains with most of the basic anilin 
dyes and by Gram's method. It takes the stain slowly but 
securely, and is with difficulty decolorized. It resists strongly 
the decolorizing action of mineral acids in common with certain 
other organisms belonging to the acid-fast bacteria. Primary 
tuberculosis of any part of the genital tract is rare, though tuber- 
culous lesions may occur in any portion. The Fallopian tubes 
are the organs most frequently infected, and next in order of 
frequency are the uterine body, ovaries, vagina, cervix, and 
vulva. Tuberculous infection of the vulva and vagina is rare, 
and is usually secondary to infection from the uterus. Tubercu- 
losis of the vagina is frequently associated with or is secondary to 
tuberculous inflammation in other portions of the genito-urinary 
tract, as the bladder, bowel, peritoneum, or distant organs, as the 
lung or joints. Primary vaginal tuberculosis, however, has 
been reported by Friedlander. It has been demonstrated 
that the freedom of the vulva and vagina from tuberculosis is 
due to the resistance of the squamous epithelium to bacterial 
invasion. Tuberculosis of the vulva and vagina (lupus), while 
extremely rare, is a very destructive disease. In one case under 
my observation in the terminal stages the entire vulva was 
totally destroyed, establishing fistulous communication between 
the vagina and rectum and vagina and bladder. I have fre- 
quently seen rectovaginal fistulas as a result of tuberculous 
disease of the rectum. Tuberculous infection of the uterus also 
is rarely a primary disease : it is generally associated with or is 
secondary to tuberculous lesions in the tubes, peritoneum, or 
some other structure of the body. Tuberculosis of the uterus 
and the organs above occurs with greater frequency than is 
clinically observed, as careful postmortem examinations of 
individuals dying from pulmonary tuberculosis has proved, 
yet Martin, in sixteen hundred examinations of the uterine 
mucous membrane, found only twenty-four instances of tuber- 
culous lesions in the uterus. According to Spaeth, tuberculous 
infection of the cervix constitutes about five per cent, of the 
cases of genital tuberculosis in women. The Fallopian tubes 
are the most frequent seat of genital tuberculosis. In a total 
of one hundred cases of pyosalpinx collected by Andrews ten 
per cent, were tuberculous. The infection is usually secondary 
to tuberculous foci elsewhere in the body. In primary tuber- 
cular salpingitis the bacilli are introduced from without, and 
attack the tube by ascending the genital canal. Secondary 
infection of the tubes usually results from tuberculous peritonitis, 
but it may also result from metastatic deposition through the 
blood- or lymph- vessels. Infection may be conveyed by contigu- 
ity of structure from a tuberculous ulcerating intestine to an 



70 GYNECOLOGY. 

adherent tube. Meyer reports fifty-seven cases of primary 
tuberculous tubal disease out of sixty-seven cases of genital 
tuberculosis. Orthmann states that primary tubal tubercu- 
losis occurs in eighteen per cent, of all cases of genital tuber- 
culous infection in women. Rosthorn, in eighteen hundred 
and fourteen cases of inflammatory disease of the tubes, found 
tuberculous infection to be the exciting cause in twent^^-nine. 
Tuberculous infection, particularly of the tubes, occurs in young 
children and in virgins. All cases of tuberculous peritonitis, 
however, are not necessarily associated with tuberculous inflam- 
mation of the tubes or uterus. I have operated on several cases 
of tuberculous peritonitis in young women, and in most of these 
careful observation failed to reveal any marked tuberculous 
process in these organs, yet some of the cases were of long dura- 
tion. It is stated by certain investigators that pre-existing 
gonorrheal infection of the tube predisposes to tuberculous 
disease. Infection of the ovaries by the tubercle bacillus is 
exceedingly rare, one or two cases of primary ovarian tuber- 
culosis having been recorded, but in the vast majority of cases 
it is secondary to tuberculous infection of the Fallopian tubes, 
peritoneum, and intestines. In forty-eight cases of ovarian 
tuberculosis Orthmann traced the infection to the tubes in 
twenty-six and the peritoneum in twenty-two. Infection of 
the peritoneum by the tubercle bacillus occurs in men, women, 
and children. The disease may occur in the acute miliary, the 
caseating, or a chronic fibroid form. The disease is most fre- 
quent in women, and the relative frequency given by different 
obsen^ers is from fifty to ninety-eight per cent. It usually 
occurs in young women between twenty and thirty years of 
age, though the infection occurs at all ages. Tuberculous peri- 
tonitis was found two hundred and eighty-four times in thirteen 
thousand four hundred and twenty-two autopsies studied by 
Grawitz and Brum, and the Mayos, in five thousand six hundred 
and eighty-seven operations, found it present eighty-nine times. 
Osier found that in abdominal operations for tuberculosis lapar- 
otomy was performed twice as often in females as in males. An 
interesting feature of tuberculous infection of the peritoneum 
is the unusual occurrence of extensive lesions in other portions 
of the body. 

109. Syphilis and Chancroid. — The organisms of chancroid 
and chancre have not been definitely demonstrated, though a 
characteristic bacillus was discovered and described first in 
chancroid by Ducrey in 1889. Unna, in 1892, described the 
appearance of this bacillus in prepared histologic sections of 
the soft sores. It appears as small oval rods measuring one 
to two microns in length and half a micron in thickness. It is 



PELVIC EXAMINATION. 71 

usually present with other organisms in the purulent discharge 
from the surface of the specific sore. It stains readily with 
basic anilin dyes, but decolorizes rapidly. It has not been 
successfully cultivated outside of the body. Regarding the 
specific organism of syphilis, much definite knowledge can not 
be given. Lustgarten, in 1884, described an organism which 
he discovered m a primary sore and in the lesions of internal 
organs. It resembles somewhat the tubercle bacillus, occurring 
in slender rods from three to four microns in length. It stains 
with the basic anilin dyes and -is easily decolorized by mineral 
acids. Lustgarten 's bacillus has not been cultivated outside 
of the body. Many other micro-organisms have been described 
as present in syphilitic lesions, but the causative relation of 
bacteria in the production of this disease has not been fully 
determined. 

no. Bacillus Typhosus. — The typhoid bacillus may be found 
in any part of the genital tract during typhoid infection, and 
for months, or even years, after subsidence of fever. It is found 
in acute infectious inflammations of the endometrium, and Pfan- 
nenstiel reported three cases of post -typhoid ovarian abscess. 
Several other cases have been reported. The typhoid bacillus 
has been found in suppurating ovarian cysts several months 
after the primary typhoid infection. It is probable that the 
bacilli reach the ovarian structure by passing through the in- 
testinal wall. Typhoid infection of the vulva and vagina also 
occurs, and, according to Keen, the lesions usually occur as dis- 
tinct vulvar gangrene and gangrenous ulcerations in the vagina. 
He collected eight cases, seven of which were in young persons 
from seventeen to twent^^-seven years of age, and one of thirty- 
four years. In six of the cases there was gangrene of the labia, 
extending sometimes to the perineum and thigh. Fistulous 
communications between vagina and bowel were established. 
The gangrenous ulcers were commonly located on the posterior 
vaginal wall. Ulceration of the anterior vaginal wall is also 
reported, with the formation of vesicovaginal fistula. In some 
of the cases great distortion of the vagina developed from cicatri- 
zation, and in one case complete occlusion, resulting in retention 
of menstrual fluid which required operation for its liberation. 
Keen reported a patient under his observation with both recto- 
vaginal and vesicovaginal fistula. Typhoid infection of the 
uterus during pregnancy frequently occurs and generally results 
in the expulsion of the fetus. Typhoid bacilli have been found 
in the placenta, and Keen studied a case reported by Freund 
and Levy in Avhich spontaneous abortion occurred at the fifth 
month. The patient Avas in the declining stages of typhoid in- 
fection. Bacilli were found in the blood of the placenta, in the 



72 GYNECOLOGY. 

Spleen, and in the heart of the fetus. Other similar cases have 
been reported. 

111. Smegma Bacillus. — This micro-organism normally in- 
habits the secretions of the external genitals, and may be found 
in the urine associated with particles of detached smegma. 
The germ is not pathogenic. Morphologically it resembles 
somewhat the tubercle bacillus, but is shorter and differs tinc- 
torially in that it is not an acid-fast bacillus, and, therefore, is 
readily decolorized by the mineral acids. 

112. Bacillus pyocyaneus, a short, rod-shaped, motile organism 
which measures one to one and one-half microns in length by one- 
half micron in width, grows readily in nearly all culture media 
at a temperature of 20° C. to 37° C, liquefying gelatin, and in 
the process of growth the colonies assume a greenish hue. It 
is found in green pus and in the discharge of the intestinal dis- 
orders of infancy. It has been found in suppurative peritonitis, 
otitis media, endocarditis, and other affections. 

113. Bacillus aerogenes capsulatus is a gas-producing bacillus, 
measuring three to six microns in length and one to one and 
one-half in thickness. It is truly anaerobic, grows in all culture 
media in chains of three and four, and generates gas and acid 
in the process of development. It has a distinct capsule. The 
germ has been found in emphysematous gangrene, in cases of 
emphysematous vaginitis, and in the uterus in puerperal septic 
infection. The distention of the puerperal uterus with gas, which 
sometimes occurs (physometra) , is, no doubt, due to the presence 
of this micro-organism. 

114. Diphtheria Bacillus. — Infection of the genital canal with 
Klebs-Loeffler bacillus while rare, occasionally occurs, and cases 
of diphtheritic infection of the vulva, vagina, and uterus are 
reported. Infection generally occurs during the puerperium 
and is implanted on injured tissues. The infectious process 
presents the same pathologic anatomy as noted when occurring 
in the throat, and responds likewise to the administration of 
antitoxin. The poison, when implanted upon abraded structures 
rapidly generates the characteristic false membrane, which hastily 
spreads over the entire vagina and even into the uterus and tubes. 
Diphtheroid infection frequently results from the presence of 
the streptococcus and other pathogenic bacteria, particularly 
the former, following labor, but the membrane formed by the 
streptococcus develops in patches and is confined to abraded 
surfaces (Edgar) ; therefore, if the entire genital tract is covered 
by the pseudo-membrane, true diphtheria is suggested. Infec- 
tion of the genital tract by the bacillus of diphtheria is usually 
conveyed by the attending physician, and it follows, therefore, 
that no case of labor should be attended by men who are at 



PELVIC EXAMINATION. 73 

the same time caring for patients suffering with diphtheritic 
infection. 

115. Pneumococcus. — The diplococcus of Frankel has been 
found in suppurative conditions of the female genital tract, 
particularly of the Fallopian tube. Andrews, in his cases col- 
lected from literature, found the pneumococcus present fourteen 
times, thirteen times in pure culture and once mixed with other 
germs. Pneumococcic infection of the genital canal, however, 
does not bear any definite relation to pneumonia. The infec- 
tion usually has been introduced from without into the lower 
genital canal. The pneumococcus has been found in suppura- 
tive processes of the ovary; it has been reported to have been 
collected in pure culture from an ovarian abscess. 

116. Diplococcus of Siegelman. — This organism occurs in 
pairs and somewhat resembles the gonococcus. It is smaller 
and is further differentiated from the gonococcus in that it 
accepts Gram's stain. The germ was discovered by Siegelman 
in several cases of pruritus vulvas in which there was no other 
demonstrable cause. Siegelman attributes, therefore, the so- 
called cases of idiopathic pruritus vulvae to the action of this 
coccus. 



ANIMAL PARASITES. 

117. Pediculosis Pubis or Inguinalis. — The ordinary crab 
louse is generally found in the hair of the pubic region, sometimes 
in the axilla, and occasionally in the eyebrows. Careful ex- 
amination will reveal the parasite near the roots of the hairs, 
with its head downward and buried in the follicle. The spores 
will be found deposited on the hair shafts. In the pubic region 
this parasite is responsible for intense pruritus, resulting in 
hyperemia and excoriation from scratching. 

118. Acarus scabiei, the itch-mite, while found on the tender 
skin areas of the body, is frequently present in the skin of the 
lower abdomen and vulva, inducing intense itching with ex- 
coriation and abrasions of the skin from constant scratching. 

119. Oxyuris Vermicularis. — The ordinary seat or pin worm 
inhabits the colon and rectum. From these regions it wanders 
to the vulva and vagina and may wend its way into the interior of 
the uterus. Fallopian tube, and ovaries. Mano, quoted by An- 
drews, reports a case of a large cyst of the ovary and two small 
cysts of the tube in which were found the eggs of this parasite. 
Mano believes that the parasite reached the tube and ovary by 
traveling from the rectum, the vagina, and uterus. The pin 
worm is found at all ages, but commonly in children. The 
parasite causes intense pruritus, which is always worse at night, 



74 GYNECOLOGY. 

due to its nocturnal migration. From the itching and scratch- 
ing, excoriations and inflammation of the vulva result, and even 
perirectal abscesses may form. 

120. Ascaris lumbricoides, the ordinary round worm of the 
intestinal canal, is the most common animal parasite found in 
human individuals. It usually occurs in children and occupies 
generally the upper portion of the small bowel. From this 
region they migrate through the various channels connected 
with the alimentary canal, and even penetrate the intestinal 
wall. Cases are recorded where they have completely occluded 
the biliary passages, and traveled through the Eustachian tube 
and projected from the external ear. They have been found in 
the vagina, uterus, tubes, and free in the pelvic cavity. J. H. 
Koch found the ascaris in an abscess in the pouch of Douglas. 
The portal of entry was through a fistulous communication 
from the rectum. Bizzozero found the ascaris in the right 
Fallopian tube ; the parasite had entered the tube by traveling 
through a perforation in the rectal wall. 

121. Taenia Echinococcus, or Dog Tapeworm. — This para- 
site inhabits the intestinal canal of the dog and wolf. The 
adult worm is composed of five segments. The first segment is 
slender and continuous with the head ; the second is the shortest ; 
and the posterior segment, the longest, is frequently more than 
half the length of the parasite. The adult worm is not found 
in the human individual. The larvae of the parasite are taken 
into the alimentary canal of the individual, or in the female 
they may enter also by way of the vagina. When conveyed 
by the alimentary canal the embryos are hatched and these 
wander into the tissues of various organs, forming a cyst, the 
hydatid cyst. In Iceland, where human beings and dogs live 
together in closely confined quarters, echinococcus disease is. 
endemic. The liver is the organ most frequently affected, 
being involved in fifty per cent, of the cases. Echinococcus 
cysts may develop in any part of the body. The disease is 
more frequent in women than in men, and Finsen found that 
in two hundred and forty-five cases seventy per cent, occurred 
in women. In the pelvis the disease is usually situated in the 
cellular tissue of the posterior pelvis and also in cellular tissue 
anterior to the uterine body. Cases have been reported where 
the cysts have developed in the uterine body proper. Hydatid 
disease develops in the Fallopian tube, and Doleris collected 
eighty cases of hydatid disease of the tube from the literature, 
one of which, his own, was possibly primary in the tube. Primary 
echinococcus infection of the ovary is rare, though a few cases 
have been reported. The diagnosis of this condition is made 
positive by finding the booklets or scolices. A cystic tumor con- 



PELVIC EXAMINATION. 75 

taining fluid of comparatively low specific gravity (1005-1012) 
and non-albuminous, or containing only a small trace of albumin, 
and neutral in reaction should be suggestive of echinococcus dis- 
ease. 

122. Collection of Fluids and Secretions. — To make a positive 
diagnosis of certain infectious conditions and to determine 
the character of the specific infectious agent present, it is neces- 
sary to collect specimens of the secretions or fluids and submit 
them to careful bacteriologic analyses. Microscopic and bac- 
teriologic examinations, however, of secretions and fluids from 
the genital tract should not be the only bases considered in 
making a diagnosis, but should be regarded as an additional 
resource for establishing the diagnosis. Bacteriologic examina- 
tions of the secretions can be made with carefully prepared 
cover-glass spreads from the vulva, vagina, and cervical canal, 
and the orifices of the various communicating glands, such as 
Bartholin's and Skene's. Spreads should also be prepared 
from secretions expressed from the urethra. The preparation 
of the spreads should not be left to the nurse, but should be 
made by the physician himself. Cover-glass specimens are pre- 
pared from the vulva by transferring the secretion from the parts 
with an applicator provided with a small swab of sterile cotton 
or the ordinary platinum needle, the end of the needle proper 
being rolled together in order to afford a larger collecting surface. 
This is applied to the part containing the secretion and then 
transferred to the cover-glass. Specimens may be secured 
from the vagina and cer\dx in a similar manner, though material 
from the cervix should be obtained after exposing the cervix 
with a speculum, when the secretion can be collected as it escapes 
directly from the cervical canal. It is important in preparing 
cover-glass spreads to collect secretion from the parts most com- 
monly the seat of infection, such as the orifice of the urethra, 
orifice of Skene's and Bartholin's glands, and from the cervical 
canal. In long-standing infections of the cervix the germs are 
found to inhabit the glands ; so to demonstrate their presence, 
therefore, the glands should be punctured and the contents 
collected on a cover-glass as they emerge at the site of puncture. 
In infecting culture media inoculations should be made with 
the suspected secretion from the different parts of the tract, 
not one part alone, and several cultures should be prepared. It 
is important in collecting discharges for bacteriologic exami- 
nation that the patient should not receive any antiseptic douche 
for at least a period of twenty-four hours before the collection 
is made. This procedure destroys the microscopic value of 
secretions and, therefore, renders examination practically worth- 
less. Cover-glass spreads can also be employed in private prac- 



76 GYNECOLOGY. 

tice — both in office work and in outside practice. The secretions 
and fluids can also be collected in especially prepared glass pi- 
pets, the material being drawn into the pipets with a syringe, 
after which the ends of the tubes are hermetically sealed. With 
the secretion contained the pipets should be enveloped in 
cotton or other protecting material and conveyed to the patholo- 
gist for examination. It is also always important in preparing 
cover-glass spreads, cultures, or secretion tubes to letter or 
number each in order to designate the organ from which the 
collections were made. Fluids from cysts are sometimes col- 
lected and examined microscopically to ascertain their true 
character, but only in hydatid disease can we deflnitely assert 
the true nature of the lesion by finding the booklets of the para- 
site. Secretions of the genital tract are, as a rule, only collected 
and examined to determine the presence and virility of bacteria 
present, although sometimes particles of benign or malignant 
neoplasms may be discharged, which are collected and studied 
intelligently, but usually only very small pieces of tissue are 
thus obtained, and from these positive microscopic diagnoses 
can not be made. Moreover, sections of material escaping 
in secretions are generally so altered by necrobiotic processes that 
the recognition of their true character is necessarily rendered 
extremely difficult. 

123. Blood Changes. — The importance of careful scientific 
blood analyses in the diagnosis of various gynecologic affections, 
particularly those of an inflammatory character, is now so 
generally recognized, as evidenced in the recent medical litera- 
ture, that the insertion of an article on this department of medi- 
cine seems necessary. The systematic and careful examination 
of the blood in certain gynecologic affections will reveal definite 
clinical facts that can not be positively elucidated by any other 
means. Gynecologic diagnoses, however, must be made by 
utilizing all clinical methods of examination, and too much value 
should not be placed on any one method. 

124. Examination of the Blood. — The blood is examined 
microscopically to ascertain the number and character of the 
corpuscles and their relative proportion, to estimate the amount 
of hemoglobin, and to determine the presence or absence of para- 
sites. The examination further involves: 

(a) The estimation of the specific gravity. 

(b) The estimation of the alkalinity. 

(c) The determination of the rapidity of coagulation. 

(d) Spectroscopic examination. 

(e) Bacteriologic examination. 

(/) The determination of the serum reaction. 

125. The Specimen. — The blood for examination is usually 



PELVIC EXAMINATION. 77 

obtained from the finger-tip or the lobe of the ear, the finger-tip 
being preferred in most instances because of its special con- 
venience. In patients nervous and easily disturbed the lobe of 
the ear should be employed, because it is not so sensitive as the 
tip of the finger. The region selected, however, should always 
be freely cleansed and kept separate from any area of infection 
or other pathologic condition. 

126. Method of Collection. — The part selected to furnish the 
specimen should be thoroughly cleansed, first with sterile water 
and then with alcohol. During the cleansing the parts should be 
rubbed briskly with a towel to dry the part, and at the same time 
cause a free determination of the blood to the parts selected. A 
puncture is made with a specially prepared needle (Fig. 52) or, 
what is undoubtedly of better service, a pen with one nib broken 
off. The part to be punctured is supported by the thumb and 
index-finger of the left hand, and slight pressure is made upon it. 
The patient, if nervous, is directed to refrain from observing the 
operation, and then with a quick, firm prick the skin is punctured. 
Dr. Coplin objects to the continuous employment of one instru- 
ment for puncturing 

or pricking the skin, 
and recommends the 
use of a pen such as 
I have described and 

which is used in my Fig. 52.— Needle for Puncturing Finger. 

service. A three- 
cornered needle or an ordinary surgical or sewing needle may be 
employed in an emergency. All the instruments used in the 
examination of the specimen should have been previously ar- 
ranged. Several cover-glasses and slides should be included, and 
these should be carefully cleansed and dried. After the first few 
drops of blood have been wiped away the summit of the next 
drop as it oozes from the puncture is touched lightly with a 
cover-glass which is placed blood side downward upon the sur- 
face of a clean glass slide or upon another cover-glass and 
drawn apart. The first method is employed if the specimen is 
to be examined in the fresh state, and the second if the speci- 
men is to be fixed and stained. The study of the fresh specimen 
can be prolonged by excluding air from the film. This is done 
by sealing the margin of the cover-glass with a thin layer of cedar 
oil or vaselin. After the cover-glass is placed upon the slide 
pressure must be avoided in order to prevent distortion of the 
cells. 

127. Microscopic Examination of a Fresh Specimen. — The 
fresh specimen thus prepared is examined with both low and high 
power lenses. The one-twelfth oil immersion, hoAvever, is the 




78 GYNECOLOGY. 

lens usually employed. The changes to be looked for in the 
erythrocytes, according to DaCosta, are any decrease in the 
number of these cells or an abnormal increase of them, corpuscular 
richness in hemoglobin, recognized when the cells appear as 
pale, washed-out bodies (abnormal viscosity, their tendency to- 
ward rouleau formation, presence of deformities, and the occur- 
rence of structural degenerative changes, and the presence or 
absence of parasites). The first change in the leukocytes to be 
noted is whether their number is greater than normal, but too 
much stress should not be placed upon an apparent increase, as 
it may be due to a reduction in the number of erythrocytes, and, 
therefore, the impression would be deceptive. To- one familiar 
with the appearance of the various forms of leukocytes in a fresh 
specimen a differential count is possible. Degenerative changes, 
ameboid movement, and pigmentation of these cells may be 
observed in examining a fresh specimen. 

The parasites found in fresh blood are those of the Plas- 
modium of malarial fever, the spirillum of Obermier, and the em- 
bryo of the filaria sanguinis hominis. Foreign bodies, such as 
fat droplets, extracellular bodies, and, rarely, Charcot's bodies, 
may also be observed. 

128. Fixation for Staining. — Cover-glass films are fixed usually 
by heat, placing the glasses in a hot-air oven at a temperature 
of 125° to 140° C. for twenty to thirty minutes. Special small 
ovens are constructed on the principle of hot-air sterilizers foi' 
the fiixation of films. The films can also be fixed by placing 
them upon a copper plate supported over a flame and protected 
from air, and also by making three or four circular turns with 
the films through a flame from a Bunsen burner, as in fixing 
bacteria. Placing the cover-glass films in equal parts of alcohol 
and ether for half an hour secures excellent fixation. 

129. Staining. — After the films are properly fixed they are 
grasped in cover-glass forceps and the stain is then applied with 
a dropper. By using Kalteyer's cover-glass forceps the film may 
be immersed in a dish containing the stain. Slides containing 
fixed blood should be placed in jars containing the stain as in 
staining tissue on slides. In staining fixed specimens and blood 
for microscopic investigation it is better, when possible, to com- 
pound preparations which will stain the largest number of ele- 
ments in the prepared blood film. This method is spoken of as 
panoptic staining. The stain most frequently used and perhaps 
endowed with special properties is the Ehrlich triacid stain. 
This stain should be made from concentrated aqueous solutions 
of the dyes. The stain is composed as follows: 

I. Saturated aqueous solution of orange G: 



PELVIC EXAMINATION. 



Orange G, 6 gm. 

Distilled water, i oo c.c. 

2. Saturated aqueous solution of acid fuchsin: 

Acid fuchsin (fuchsin S), 9 gm. 

Distilled water, too c.c. 

3 . Saturated aqueous solution of methyl green : 

Methyl green (00 crystal), 6 gm. 

Distilled water, 1 00 c.c. 

These solutions keep fairly well, but the mixed stain pre- 
pared from them is not a lasting one and, after a period of two 
or three weeks, usually does not act well, but even then an 
experienced investigator will recognize the deficient dye, and can 
add the required stain. Films stained by Ehrlich's method will 
show the stroma of the red cells an orange hue ; the nuclei of 
the white cells greenish-blue ; the neutrophile granules violet or 
lavender, and the eosinophile granules copperish red. Nucleated 
red cells of normal size, according to DaCosta, stain deep purple 
or black; those of normal size (normoblasts) and those of large 
size (megaloblasts) pale or greenish-blue. The basophile gran- 
ules do not take the stain and appear as a dull Avhite coarseness 
in the cell protoplasm^. The methylene-blue eosin stain, introduced 
by Wright, is one of the most satisfactory now in use, and the one 
introduced by Jenner is also of value. Preparations having 
qualities similar to the Wright and Jenner stains have been advo- 
cated by other men. The chief advantages claimed for these 
agents are that no special fixation of films is required and that 
blood plates and basophilic granules and the malarial parasites 
are all well stained by these preparations. The Wright stain is 
employed as follows: (i) Cover thin, air-dried films with stain 
for one minute. (2) Add to the stain water, drop by drop, until 
an iridescent scum forms on the surface ; for seven-eighths inch 
square cover-glass films four to eight drops of water usually suf- 
fice. Allow the diluted stain to act for two or three minutes. 
(3) Wash with water until the film becomes pink or yellow in 
color. (4) Blot with filter-paper, dry in air, and mount in balsam. 
Under the microscope the erythrocytes will appear orange or 
pink ; nuclei of leukocytes and erythroblasts a dark blue to lilac ; 
cytoplasm of lymphocyte robin's-egg blue; hyaline cell, pale to 
dark blue; neutrophile granules, reddish lilac; eosinophile gran- 
ules, pink ; basophile granules, blue to royal purple ; blood plates, 
pale blue with dark lilac or blue granules. After washing off 
Ehrlich's stain, Dr. Hewes recommends that a saturated aqueous 
solution of meth^dene-blue should be used as a stain for several 
minutes. Cabot savs that anv one who has used this Ehrlich 



80 GYNECOLOGY. 

methylene-blue stain will never employ any other for clinical 
purposes. The blue count erstain also brings out clearly the out- 
lines of the parasite against the yellow of the corpuscle. Many 
other methods of staining blood specimens have been rec- 
ommended, but the stains thus enumerated will serve practically 
every clinical purpose. 

lodopkilia. — The behavior of leukocytes to iodin, originally 
described by Ehrlich and Gabritschowsky, is a decided progressive 
step in the clinical examination of the blood. This reaction of 
the leukocytes to iodin is called iodophilia, while the cells taking 
the iodin are spoken of as iodophiles. The reagent employed to 
obtain the iodin reaction is a syrupy mixture, composed of the 
following elements: 

Iodin, I 

Potassium iodid, 3 

Aqua dest., 100 

Gum arabic sufficient to make syrupy mixture. 

This syrupy solution is placed upon an air-dried film of blood 
for two or three minutes. The excess is then drawn off and the 
cover-glass placed blood side downward on the slide. Under the 
microscope the red cells, leukocytes, and blood plasma of a normal 
specimen are found to stain a uniform pale yellow. In a positive 
iodin reaction the leukocytes stain brown, either diffusely or 
in a granular or network distribution. As a rule, variable sized 
granules, ranging in color from brownish yellow to a deep brown, 
are found, which, in location, are intracellular or extracellular. 
These brownish, granular bodies are found within the polynuclear 
leukocytes. The presence of iodophilia may be generally con- 
sidered indicative of a septic or suppurative process. It is not, 
however, a positive sign of the presence of pus. DaCosta says 
that a reaction is positive in all purulent collections, and that the 
reaction persists as long as the suppurative focus exists. It is 
present in puerperal sepsis and other forms of septicemia. It is 
not found in pure tuberculous formations, and, therefore, the 
presence of iodophilia in all other forms of abscess may be the 
deciding factor in the differential diagnosis of pus accumula- 
tions. This peculiar reaction of the leukocytes to iodin is also 
a valuable diagnostic agent in other diseased conditions which 
are of more interest to the general practitioner than the gyne- 
cologist. 

130. Counting the Corpuscles. — The instruments employed for 
counting the corpuscles are called hemocytometers. An instru- 
ment devised by Thoma is the one in most common use, and is 
regarded as the standard for blood counting. It consists of two 
graduated pipets for diluting and mixing blood, and a counting 
chamber in which a measured volume of diluted blood is placed 



PELVIC EXAMINATION. 81 

for the purpose of counting the corpuscles under the microscope. 
(Fig. 53.) One of the pipets is intended for counting the 
er3rthrocytes or red cells, and, therefore, is spoken of as the red 
pipet or erythrocytometer. The other pipet, used for count- 
ing the leukocytes or white cells, is called the leukocytometer. 
The pipets are graduated in order to secure accuracy in dilution. 
The blood is drawn into the tubes to an indicated point, and then 
the diluting solution. The tube is thoroughly agitated in order 
to mix the blood completely with the diluent. For ordinary 
counting a one-half of one per cent, or a one per cent, solution of 
sodium chlorid is used as a diluting agent for the erythrocytes, 
and a one per cent, or a one-half of one per cent, aqueous solu- 
tion of acetic acid is used as the diluting agent for the leukocytes. 
This acid solution is used in order to dissolve out the erythrocytes 




titiYt'iVtfTl 

Fig. 53. — Hematocytometer. 

and at the same time render clear the leukocytes. Diluting fluids 
are also used to secure different shading of the corpuscles dur- 
ing the process of counting. The most satisfactory for this pur- 
pose is Toisson's solution, composed as follows : 

Methyl-violet, 0.025 &i^- 

Sodium chlorid, i.o " 

Sodium sulphate, 8.0 " 

Glycerin, 30.0 c.c. 

Distilled water, 160.0 " 

Or the following solution of Sherrington may be employed : 

Ehrlich's purified methylene -blue, o.i gm. 

Sodium chlorid 1.2 " 

Neutral potassium oxalate, 1.2 " 

Distilled water, 300.0 " 

131. The Estimation of Hemoglobin. — The estimation of the 
percentage of hemoglobin is determined by the hemoglobinometer. 
Several instruments have been devised for this purpose, but the 
6 



82 



GYNECOLOGY. 



hemoglobinometer originated by Dr. Dare is one of the best. 
(Fig. 54.) It is of simple construction, easy of manipulation, and 
answers every purpose well. The instrument of von Fleischl is 
also extensively used, but it is more complicated and requires 
more time in manipulation than 
the Dare instrument. The Tall- 
qvist hemoglobin scale is simple 
and good for use in emergency. 
It is composed of a book (Fig. 55), 




1 ' sPH 





Fig. 54. — Dare's Hemoglobinometer. 
R. Milled wheel acting by a friction 
bearing on the rim of the color disc. 
S. Case inclosing color disc, and pro- 
vided with a stage to which the 
blood chamber is fitted. T. Movable 
wing which is swung outward during 
the observation, to serve as a screen 
for the observer's eyes, and which 
acts as a cover to inclose the color 
disc when the instrument is not in 
use. U. Telescoping camera tube, 
. in position for examination. V. 
Aperture admitting light for illu- 
mination of the color disc. X. Capil- 
lary blood chamber adjusted to stage 
of instrument, the slip of opaque 
glass, W, being nearest to the source 
of light. Y. Detachable candle- 
holder. Z. Rectangular slot through 
which the hemoglobin scale indi- 
cated on the rim of the color disc is 
read. 



Fi< 



55-- 



-Tallqvist's Hemoglobin 
Scale. 



a color scale forming the first 
leaf, and the remaining leaves 
being composed of absorbent 
paper. This apparatus, how- 
ever, is only approximately 
accurate. 

132. Composition of 
Blood. — The normal circula- 
ting blood is composed of two 
portions. The first, the liquid 
portion, known as the liquor 
sanguinis or blood plasma, 
and a solid portion, which is 
composed of corpuscles or 
blood-cells. The plasma is a 
straw-colored fluid with a specific gravity ranging from 1026 to 
1030. It is alkaline in reaction and contains approximately ten 
per cent, of solid matter, of which three-fourths are proteids and 
the remainder fibrinogen, serum-albumin, and serum-globulin. 



PELVIC EXAMINATION. 83 

The corpuscles are of two varieties: i, Erythrocytes, or red cells; 
2, leukocytes, or white cells. Besides these, two other elements 
are found: namely, the blood plaques or platelets, and the 
hemoconia, or "Miiller's dirt." The salts of the blood consist of 
sodium chlorid, potassium chlorid, sodium carbonate, sodium 
phosphate, magnesium phosphate, and calcium phosphate. Of 
these, the sodium chlorid is the most abundant and forms from 
sixty to ninety per cent, of the total amount of mineral matter. 

133. Erythrocytes. — The erythrocytes or red corpuscles in 
man are thin, non-nucleated, biconcave discs. From seventy to 
eighty per cent, of the red cells have an average diameter of 
7.5 microns. Of the remaining twenty per cent, about one -half 
are slightly larger and the remaining slightly smaller. Unduly 
small red corpuscles are called microcytes, and when these are 
abundant in the circulating blood, the condition is spoken of as 
microcytosis. Unduly large red cells are known as macrocytes ; 
regular shaped erythrocytes, as found in certain diseases, are 
called poikilocytes, and where this is marked, the condition is 
denominated poikilocytosis. The term " blast " is applied to red 
cells containing nuclei. The normal red cells containing nuclei 
are called normoblasts, small cells containing nuclei microblasts, 
and the extremely large cells containing nuclei macroblasts. 
Poikilocytes containing nuclei are called poikiloblasts. 

The hemoglobin or coloring-matter of the blood is a highly 
complex albuminoid substance contained within the stroma of 
the red blood-cells. It forms about nine -tenths of the total bulk 
of the erythrocytes, and its special function is to convey and dis- 
tribute oxygen to the tissues in its passage through the capillary 
circulation. The normal percentage of hemoglobin is fixed at 
one hundred, but in estimating this element in individuals 
apparently normal, one hundred per cent, is rarely obtained. 
One hundred per cent., however, is considered normal, and this 
means that every one hundred gm. of blood contains approxi- 
mately fourteen gm. of hemoglobin. A reduction in the per- 
centage of hemoglobin is called oligochromemia. This condition 
characterizes, as a rule, all the primary and secondary anemias. 
It is usually associated Avith a diminution in the number of red 
cells. Pronounced reduction in the hemoglobin is present in 
chlorosis, pernicious anemia, leukemia, and in the secondary 
anemias — those resulting from hemorrhage, acute and chronic 
infections, malignant disease, and general systemic exhausting 
diseases. A slight reduction (ten to fifteen per cent.) usually 
occurs a few days prior to menstruation. 

134. Color Index. — The normal color index or valeur globu- 
laire of the blood is the amount of hemoglobin in the individual 
red cell. 



84 GYNECOLOGY. 

135. Relation of Hemoglobin to Surgery. — Many investigators 
have asserted that it is dangerous to administer an anesthetic or 
operate upon patients when the hemoglobin is below thirty per 
cent., while others claim that forty per cent, should be fixed as 
the minimum safety. In my experience the standard thus fixed 
is too high, and I believe that with a hemoglobin percentage of 
twenty per cent, anesthesia can be induced and operations per- 
formed with wisdom and safety. I have operated upon several 
patients successfully with a hemoglobin percentage ranging be- 
tween tAventy and thirty per cent. In one patient, indeed, the 
percentage was but nineteen. This patient was suffering with 
extensive malignant disease of the uterus. I performed a com- 
plete hysterectomy and the patient made an uninterrupted re- 
covery. I would not, however, insist that it is wise to operate in 
all cases where the hemoglobin percentage is inordinately low. 
I believe it better, when the condition of the patient will permit, 
to wait and employ means to increase the hemoglobin richness 
of the blood, but where this can not be done, particularly in cases 
of progressive exhaustive disease, I believe operation indicated 
despite the presence of a low hemoglobin percentage. One of 
the principal objections, however, to operation on patients with 
profoimd oligochromemia is the failure of the wound to unite 
readily. In one patient upon whom I operated for uterine carci- 
noma and who had only twenty per cent, of hemoglobin, the tissues 
failed to unite, and with the removal of the sutures the abdominal 
incision separated, exposing the intestine. Low hemoglobin per- 
centage also predisposes patients to shock, infection, and in all, 
convalescence is prolonged and disturbed. 

The normal nucleated red cell is regarded as an immature 
form of the erythrocyte, and is found normally in the bone-mar- 
row, and only in the peripheral blood when special demands are 
made upon the blood-making organs for cellular elements, as in 
certain pathologic states, particularly the anemias of both the 
primary and secondary varieties. 

136. Normal Number of Red Cells. — At ordinary sea level and 
in the adult normal individual the average number of red cells to 
the cubic millimeter of blood is five million in man and four mil- 
lion five hundred thousand in woman. In the robust, healthy 
person this number may be increased to five million five hundred 
thousand, six million, or more. Altitude above the sea level raises 
the count. Concentration of blood from various causes will also 
increase the number of erythrocytes. The influence of menstrua- 
tion, childbirth, lactation, and digestion is to cause a temporary 
decrease in their number. Prolongation of exercise reduces the 
number. In the newborn the red cell count is high (seven to 
eight millions). 



PELVIC EXAMINATION. 85 

137. Increase in the Number of Erythrocytes. — An increase in 
the number of erythrocytes above what is fixed as the normal 
standard is called polycythemia. A decrease in the number is 
known as oligocythemia. 

138. Pathologic Alterations of the Erythrocytes. — Ameboid 
movements are said to have been observed in the red cells in cer- 
tain pathologic states of the blood. Disassociation of the hemo- 
globin from the stroma is also observed in certain diseased 
states. In most inflammatory conditions and in the profound 
anemias a hyperviscosity of these elements is observed. De- 
formity of shape and size of the red corpuscle is noted in all the 
severe anemias. The terms applied to the alteration in size and 
shape were mentioned in discussing the physiology of these cells. 
Polychromatophilia or abnormal staining reaction occurs in 
several forms of anemia, and is particularly noted in pernicious 
anemia and myelogenous leukemia. Nucleation of red cells is 
noted in various pathologic conditions, and the various forms of 
nucleated red cells (erythroblasts) have been mentioned. Gran- 
ular changes of the protoplasm in the red cells occurs in certain 
pathologic states, but is most constant in chronic plumbism. 
This granular change is present also in pernicious anemia, leu- 
kemia, carcinoma, malaria, septicemia, and chronic suppuration. 
The granules in the erythrocyte are basophilic, and they may be 
distributed throughout the cell or aggregated in small masses. 
The size of the granules varies. The presence of basophilic 
granulating erythrocytes is spoken of as basophilia. 

139. Platelets. — The blood platelets or blood plaques are 
small spherical bodies, somewhat smaller than the erythrocyte. 
They are of a pale yellowish tint and measure one to four microns 
in diameter. They are non-nucleated bodies and react to both 
basic and acid stains. Their normal number to the cubic milli- 
meter of blood is fixed at from one hundred and eighty to four 
hundred thousand, and by some men their number is fixed at 
■eight hundred and sixty thousand. They are non-nucleated and 
do not contain hemoglobin. Many observers claim that they 
have their origin in extruded particles of the erythrocytes, while 
others believe they originate from the nuclei of leukocytes. They 
are the chief constituents of white thrombi. These bodies are 
increased in most of the anemias. They are present in pneu- 
monia, tuberculosis, and other conditions. They are diminished 
in purpura, hemophilia, and in acute infections. 

140. Hemoconia. — In normal and pathologic blood, elements 
have been described by Miiller to w^hich he applies the term 
' * hemoconia' ' or * ' blood dust . ' ' This material is present as small, 
round, colorless granules which measure from one-fourth to one 
micron in diameter. These bodies are refractile and have the 



ob GYNECOLOGY. 

power of molecular action, but no true ameboid movement. 
Their presence in the blood is not of special diagnostic or prog- 
nostic value, though by some men they are believed to bear some 
relation to the process of immunity. Their true origin is not 
known. Some claim that they are products of the erythrocyte, 
while others present evidence to show that they are granular 
bodies derived from neutrophile and eosinophile leukocytes. 
Hemoconia is also found in pus and in hydrocele fluid. 

141. Leukocytes. — The leukocytes or white blood-cells are 
pale, nucleated bodies, the greater portion being larger in size 
than the red cells, but, unlike the red cells, they are found in 
several varieties. The proportion of leukocytes to erythrocytes 
varies, but it ranges approximately between one of the red cells 
to five or six hundred of the white cells. The size of the normal 
leukocytes varies from seven to twelve microns. The general 
outline while at rest is an irregular ellipse. The total number 
of leukocytes in a cubic millimeter of normal blood is given at 
from four to ten thousand. The mean normal average has been 
set at seventy-five hundred per cubic millimeter. The number of 
leukocytes present in the blood varies to a considerable degree 
under physiologic conditions. Several varieties of white cells 
are found in stained specimens of fresh blood. The different 
varieties and the percentage present and the number per cubic 
millimeter in the normal blood are given in the following table : 

Variety. Percentage. Cubic Millimeter. 

Polynuclear neutrophiles, 60 to 75 3000 to 7500 

Small lymphocytes, 20 to 30 1000 to 3000 

Large lymphocytes and transitional 

forms, 4 to 8 200 to Soo 

Eosinophiles, 0.5 to 5 25 to 500 

Basophile rarely exceeds 0.5 25 

As stated before, these percentages vary greatly under both 
physiologic and pathologic conditions. 

Decrease in the number of leukocytes is called leukopenia, 
or hypoleukocytosis. Leukopenia occurs in certain of the in- 
fectious diseases, such as typhoid fever, measles, influenza, 
malarial fever, and also in uncomplicated tuberculosis. It is 
also present in certain of the primary anemias and in some 
secondary anemias. In conditions characterized by an increase 
in the number of leukocytes a reduction is sometimes noted. 
This is due to the overwhelming influence of the toxin and is 
said to be of graA^e significance. It signifies the patient's in- 
ability to combat the infectious process. Leukolysis, or the de- 
struction of leukocytes, most marked in the polynuclear cell, 
occurs in suppurative processes. Pus-cells are polynuclear cells 
altered by the action of bacterial poisons. 



PELVIC EXAMINATION. 87 

142. Leukocytosis.— This theory teaches that the circulating; 
blood contains certain bodies (chemotactic) of a chemical nature 
which have an attractive and repellent influence upon the phago- 
cytes. Chemotaxis is both positive and negative — positive when 
the cells are attracted by chemotactic bodies and negative 
chemotaxis when the cells are repelled by these substances. 
Leukocytosis may be defined as an increase in the number of the- 
Avhite cells over the normal number in the peripheral circulating 
blood. The increase may be absolute and relative in the poly- 
nuclear cell with a relative decrease of the other forms, or the 
increase may be general in all varieties alike, but the increase 
never involves a diminution of the polynuclear forms ; therefore 
leukocytosis is of two kinds : ( i ) That in which the relative pro- 
portion of the different varieties to each other is unchanged; (2) 
that in which the increase is made up solely or largely by a gairt 
in the polynuclear leukocytes. Leukocytosis may be temporary 
or permanent. The latter is spoken of as chronic leukocytosis. 
Leukocytosis is divided into — (i) physiologic leukocytosis; (2) 
pathologic leukocytosis. Physiologic leukocytosis is classified 
under the following heads: leukocytosis of the newborn; leu- 
kocytosis of digestion; leukocytosis of pregnancy and parturi- 
tion ; leukocytosis due to thermal and mechanical agencies ; and 
leukocytosis of the moribimd state. Physiologic leukocytoses 
are generally of short duration and are characterized by only a 
moderate increase in the leuk:ocytes. The causes of physiologic 
leukocytosis are said to be an tmequal distribution of the cells 
in favor of the peripheral vessels and upon the temporary con- 
centration of the blood. 

143. Leukocytosis of Digestion. — Leukocytosis of digestion 
rarely reaches a high count, but after a meal rich in proteids 
the count may rise to thirty-three per cent. Ten thousand cells 
maybe considered the average, according to Cabot, three or four 
hours after a rich meal. 

144. Leukocytosis of Pregnancy and Parturition. — Leuko- 
cytosis occurring in pregnancy is most marked in primiparce. 
Thirteen thousand is considered an average count, and is 
quite constant. In multiparse it occurs in only about fifty per 
cent, of the cases. Leukocytosis of the parturient state may 
endure for several weeks and is important for the reason that it 
may be mistaken for a pathologic leukocytosis. 

145. Thermal and Mechanical Agencies. — Thermal and me- 
chanical leukocytosis results from blood concentration, and this 
is due to vasomotor contraction with increased arterial tension. 

146. Terminal leukocytosis, or leukocytosis of the moribund 
state, occurs in many cases. It is not present if death is sudden 
or rapid. It seems to be analogous to the preagonal rise_of 



88 GYNECOLOGY. 

temperature. The increase in ordinary cases occurs in the 
polynuclear cell. 

147. Pathologic Leukocytoses. — Pathologic leukocytoses are 
classified as posthemorrhagic, inflammatory, malignant, toxic, 
and experimental. The exact cause of pathologic leukocytoses 
has not been determined, but the general belief at the present 
time is that the increase is due to chemotactic influence. 

148. Posthemorrhagic Leukocytosis. — Leukocytosis results 
from loss of blood, is rapid in its development, and of short dura- 
tion. The count may reach sixteen to eighteen thousand. The 
increase, as a rule, is in the polynuclear cell. 

149. Leukocytosis (Phagocytosis). — The function of leuko- 
cytosis is to protect the individual against infectious micro- 
organisms and their toxins. It is one of nature's methods of 
antagonizing and rendering inert micro-organisms and their 
poisons. Cells having this power are called phagocytes, and 
they exert their force in two ways: (i) By mechanically destroy- 
ing the infectious generators of bodies (bacteria); and (2) by 
the generation of chemical products (alexins) which are an- 
tagonistic to the bacterial poison and destructive to bacteria 
also. 

150. Inflammatory Leukocytosis. — This variety of patho- 
logic leukocytosis, as its name implies, is associated with suppura- 
tive, septic, or inflammatory processes. It should not be, ac- 
cording to Cabot, described as infectious leukocytosis, for the 
reason that in many of the infectious diseases the leukocytes 
are not increased. Furthermore, in certain infectious diseases 
there is an actual diminution (leukopenia) in the number of 
white cells. The extent or degree of leukocytosis depends: 
(i) Upon the reaction of the patient; and (2) upon the virulence 
of the invading micro-organisms. Therefore, a high leukocy- 
tosis usually indicates good reaction and strong resistance upon 
the part of the patient and is considered a favorable prognostic 
sign. Persistent hypoleukocytosis in the presence of infection, 
however, indicates lessened tissue reaction and virulent infec- 
tion. The leukocytic count in inflammatory conditions varies 
greatly. It is not unusual to find a leukocytosis of forty-five 
thousand, forty-eight thousand, or fifty thousand, and even 
greater. The individual cell most prominent in inflammatory 
leukocytosis is the polynuclear leukocyte, and this type forms 
from ninety to ninety-five per cent. In other cases the in- 
crease is found in the lymphocyte. Leukocytosis in inflamma- 
tory diseases of the female genital tract is quite constant and of 
value as a diagnostic aid in pelvic conditions. A leukocytosis 
ranging from twelve thousand to eighteen thousand as a rule 
indicates suppurative disease in the adnexa, if other causes can 



PELVIC EXAMINATION. 89 

be excluded. Pankau believes that a leukocyte count of ten 
thousand indicates suppuration in the appendages. DaCosta 
found in thirty -four cases of pelvic abscess, ovarian abscess, 
and pyosalpinx, an average leukocyte count of fifteen thousand 
five hundred and forty-eight per cubic millimeter. Of course, 
the increase in the number of leukocytes will depend upon 
the degree and limitation of the suppurative process. If an 
abundance of the toxic material is absorbed from the pelvic 
lesion and the resistance of the patient is good, the increase will 
be marked, while if the lesion is enveloped by a non-absorbing 
inflammatory wall, the count will be low. 

151. Malignant Leukocytosis. — According to Julliard, in 
malignant disorders leukocytosis is not present early, but is 
associated with ulceration, necrosis, and absorption of specific 
toxic matter. When generalization of malignant neoplasms 
occurs, the leukocyte count rises, providing the patient still re- 
tains powers of reaction. The effect of malignant disease on 
the leukoc3rtes will depend upon:, (i) The position of the tumor; 
(2) its size ; (3) rapidity of growi:h ; (4) the occurrence of metastases ; 
(5) the resisting power of the individual; and (6) the degree of 
necrotic change. In cancer of the uterus the leukocytes are, 
as a rule, slightly increased. In seven cases reported by Cabot 
a leukocytosis was observed in five which ranged from sixteen 
thousand eight hundred to thirty-four thousand. In the two 
remaining cases no decided alteration was noted in the number 
and appearance of the leukocytes. It may be said, however, 
that malignant leukocytosis is generally moderate, and, accord- 
ing to DaCosta, counts of less than twenty thousand are the 
general rule. Malignant leukocytosis is generally most pro- 
nounced in sarcoma. 

152. Toxic Leukocytosis. — Increase in the leukocytes due 
to uric-acid diathesis, quinin poisoning, illuminating gas poison- 
ing, intestinal intoxication, nephritis, chloroform narcosis, and 
the ingestion of certain chemicals is spoken of as toxic leuko- 
cytosis. 

153. Experimental Leukocytosis. — This is an increase in 
the number of leukocytes due to the administration of certain 
drugs. Artificially induced leukocytosis or leukotaxis has been 
resorted to in order to increase the local and general resistance 
of individuals against infection. Petit endeavored to increase 
infection resistance of the peritoneum by the injection of heated 
horse serum, and for the same purpose Mikulicz employed on 
patients preparatory to operation injections of nucleinic acid 
hypodermically. I have used the latter for this purpose, but 
am unable from my experience to assert any beneficial infiuence. 
The increase produced by artificially induced leukocytosis occurs 



90 GYNECOLOGY. 

in the polynuclear cells, which is asserted to be from nine to 
four hundred and twenty-five per cent. 

154. Bacteremia. — Bacteremia is defined as the presence of 
micro-organisms in the circulating blood. Normally the blood 
is regarded as bacteria-free, yet recent investigations show that 
even under normal conditions bacteria exist in the blood. The 
condition has been denominated "latent microbism." This 
mild bacteremia is wholly consistent with health, because the 
bacteria present are small in number and not virulent, and, 
therefore, can not do harm unless the individual is weakened 
in resistance and the bacteria become virulent. 

155. Bacteria found in Blood. — A large number of bacteria 
have been isolated from the circulating blood. Among the most 
important are: 

I. The pyogenic bacteria. 

(a) Staphylococcus pyogenes. 

(b) Streptococcus pyogenes. 

(c) Gonococcus. 

(d) Pneumococcus. 

(e) Diplococcus intracellularis meningitidis. 
Other bacteria found in the blood are : 

Bacillus anthracis. 

Bacillus coli communis. 

Bacillus influenzae. 

Bacillus leprae. 

Bacillus mallei. 

Bacillus pestis. 

Bacillus tetani. 

Bacillus tuberculosis. 

Bacillus typhosus. 
Besides these vegetable parasites, certain animal parasites 
are found in the blood, the most important of which are the ma- 
larial Plasmodia, the embryo of the filaria, and spirilla of Ober- 
meyer. 

156. Blood Culture. — The blood secured for bacteriologic 
examination should be aspirated by puncturing a superficial 
vein which has been exposed by an incision, and not by punc- 
turing the vein through the skin. Examination of prepared 
cover- glass films is unsatisfactory. In obtaining the blood 
the veins in front of the elbow- joint (median basilic or median 
cephalic) may be selected. The tissues of the part should be 
thoroughly sterilized in order to rid them of the common dermal 
bacteria. According to DaCosta, fluid culture media are pref- 
erable to the solid. One-half cubic centimeter of blood should 
be drawn for each culture, and about one hundred parts of media 
to each part of blood should be used. A special needle can be 



PELVIC EXAMINATION. 



91 



secured for withdrawing the blood (Fig. 56), but in an emer- 
gency a sterile antitoxin or hypodermic syringe may be em- 
ployed. 

157. Blood Coagulation. — The coagulation of the blood 
under normal conditions is stated to occur, as a rule, in about 
five minutes, but, according to the personal observations of 
Coplin, a considerably longer time is required. Several methods 
are recommended to determine time of coagulation, but none 
are entirely satisfactory. A convenient method is that utilized 
by Milieu, which consists in placing a large drop of blood on a 
thoroughly clean slide, which after a few minutes is tilted toward 
a vertical plane to determine whether the shape of the drop is 
changed thereby. The hemogilometer of Biffi or the coagu- 
lometer of Wright may also be used to determine the time of 
coagulation. A proper knowledge of the coagulability of the 
blood is important to the surgeon in certain conditions requiring 
surgical intervention, and 

this will govern him in 
adopting and carrying out 
the proper course. The 
coagulability of the blood is 
decreased in cases of ob- 
struction of the biliary pas- 
sages, as in cholelithiasis 
with or without icterus, in 
acute exanthemata, in pur- 
pura, hemophilia, and other 
forms of blood dyscrasia. I • Fig. 56. 
recall two deaths resulting 
from uncontrollable oozing 

after operations upon patients suffering from jaundice produced by 
cholelithiasis. Therefore, before operating upon patients suffering 
from lesions associated with decreased coagulability of the blood, 
proper treatment should first be instituted to restore the blood 
to as near a normal condition as possible, and thus increase the 
safety of operative interference. 

158. Exploration of the Urethra, Bladder, and Ureters. — The 
bladder can be explored by the introduction of the finger through 
the urethra, but the dilatation required is so great that, notwith- 
standing every precaution which can be exercised, the procedure 
must necessarily often be followed by loss of sphincter control. 
A careful urethral and vesical examination may be made de- 
sirable by frequent and painful micturition, by admixture with 
the urine of blood, pus, desquamated epithelium, fragments of 
tissue, and the presence of bacteria. Limitation of the inflam- 
mation to the urethra is indicated by a pain and burning during 



|iN 




-Special Needle for Securing 
Blood. 



92 GYNECOLOGY. 

the act of urination, followed by comparative comfort (unless 
complicated by cystitis) unaccompanied by frequency of micturi- 
tion. Inspection will reveal the orifice of the inflamed urethra 
as red, pouting, and angry. Frequently by pressure along the 
course of the canal from above downward a drop or two of dirty 
or purulent fluid will be expressed. When the inflammation 
involves the w^all of the urethra, it can readily be distinguished 
upon palpation of the anterior vaginal wall as a distinct cord- 
like projection. Skene's urethral endoscope is of value in de- 
termining the condition of the urethral mucous membrane. (Fig. 
57.) It discloses points of inflammatory redness, desquamated 
epithelium, thickened membrane, and fissures of the internal 
urethral orifice. The instrument should not be unduly large, 
as the distention of the urethra obscures pathologic alterations. 
Irritation and inflammation of the bladder is indicated by fre- 
quent and painful micturition and violent tenesmus unrelieved 
by urination. The attacks may recur and appear to be induced 
by exposure to colds, as drafts, changes of temperature, damp- 
ness, indiscretions in diet and drinking, and by excessive venery, 
or the discomfort may be more or less continuous. The distress- 
ing symptoms may have arisen from infection which has reached 
the bladder from the urethra, the kidney through the vesical walls, 
or from the presence of foreign bodies, as calculi, fragments of 
catheter, or extraneous bodies which have been inserted into the 
urethra in the process of onanism. The existence of the various 
neoplasms may be manifested by similar symptoms. Inflam- 
mation of one or both ureters is prone to be associated with pain, 
which may be referred to the bladder. Incontinence of urine 
association with a forcible dejection of the fluid in small quantities 
is especially characteristic of inflammation of the ureter. Ex- 
amination of the urine is of particular value in the determination 
of the lesions of the various portions of the urinary tract. In 
urethritis and functional irritation of the bladder, the urine will 
be clear and free from deposits. In cystitis, ureteritis, and pyel- 
itis the urine may be loaded with sediment, which under the 
microscope will be found to consist of blood and pus corpuscles, 
renal and vesical epithelium, portions of tissue, crystals of the 
various salts, and in some cases casts of the uriniferous tubules. 
The determination of the portion affected by the character of 
the desquamated epithelium is impracticable. The examination 
of the urine secured after careful irrigation of the bladder, or, 
better still, after the catheterization of the ureters, not only 
differentiates renal from vesical conditions, but affords informa- 
tion as to the state of the individual kidney. If after irrigation 
of the bladder the urine secured is clear and comparatively free 
from sediment, it is a fair inference that the disorder is confined 



PELVIC EXAMINATION. 93 

to the bladder; and, on the contrary, the continuation of pus, 
blood, and desquamated epithelium in the urine is an intimation 
that the upper urinary structures are the seat of disease or are 
actively involved by it. Inflammation of the bladder causes the 
secretion of a large quantity of mucus, and the urine contains 
but little albumin, while in inflammation of the pelvis of the 
kidney the proportion of albumin is comparatively large. Pyel- 
itis is distinguished from nephritis by the absence of tubular 
casts. Bloody or high colored urine is not uncommon in acute 
inflammation of the kidney or bladder. Hemorrhage from the 
urinary tract may occur from a variety of causes and from any 
portion of the tract. From the urethra it may occur indepen- 
dently of urination as a few drops or clots in the first discharge 
of urine, or after the completion of micturition. Vesical hemor- 
rhage may cause the urine to be bright red or appear as almost 
pure blood, according to the severity of the hemorrhage. When 
very profuse, the bladder may become filled with clot, so that the 
patient is unable to void urine, and the presence of the clot 
interferes with catheterization. Free bleeding from the kid- 
ney may be seen with the cystoscope (see Fig. 58), and makes 
its exit from one of the ureters as pure blood or distinct casts 
of the ureter may be found in the urine, and the patient gives 
a history of having had severe pain over the kidney and along 
the ureter corresponding to the side from which the hemorrhage 
has occurred. Pain is a characteristic symptom. It is felt above 
the symphysis in cystitis, along the affected ureter in ureteritis, 
or over the affected kidney in pyelitis, or where the kidney con- 
tains a calculus. The hypogastric region is tender to pressure, 
in cystitis the tenderness being more noticeable upon sudden 
withdrawal of the hand after deep pressure when tubercular 
cystitis exists. The bladder may be palpated by one or two fin- 
gers in the vagina and the hand over the abdomen. The inflamed 
bladder will be thickened, contracted, and very tender. Calculi 
and neoplasms may thus be recognized. The inflamed and 
thickened ureter is easily recognized upon one side or upon both 
sides when bilateral. The shortened ureters stand out as firm, 
dense cords. Not infrequently in such cases the pressure along 
the ureter may cause a sudden discharge of urine, which may 
reach the person of the investigator. The inflamed kidney is 
readily palpated when the patient assumes the dorsal position 
with the limbs flexed. The physician stands upon the affected 
side, places one hand upon the back beneath the ribs, and pushes 
gently forward, while at the same time the patient is asked to 
take a long breath and allow it to be expelled quickly. Pressing 
the thumb of the hand beneath the ribs in front during expiration 
the enlarged kidney may be felt to have slipped upward, or, where 



94 



GYNECOLOGY. 



it is quite movable, may be held below the fingers. In thin 
patients the kidney may thus be easily distinguished. Care must 
be exercised, however, that a prolapsed or malformed liver is 
not mistaken for the kidney. During the first week in July, 
1906, I saw a woman who, I was convinced after an examination 
under an anesthetic, had a very movable kidney, but examina- 
tion through an abdominal in- 
cision, which was made for short- 
ening the round ligaments, re- 
vealed the fact that the supposed 
movable kidney was a tongue - 
like projection from the anterior 
margin of the liver which, through 
the abdominal wall, greatly re- 
sembled in size and shape the 
kidney. Pawlik and Kelly de- 
vised specula through which the 
bladder could be inspected and 
medications applied to the most 
affected portion. The orifices of 
the ureters could be inspected 
and the ureteral catheter em- 
ployed. They require the urethra 
to be dilated, sometimes close to 
or beyond the limit of safety, in 
order to afford opportunity to 
inspect and properly treat the 
affected structures. Of late 





Fig. 57. — Skene's Urethroscope. 



A\\ B C ,,C:^ D 

Fig. 58. — Cystoscopes. 



years the procedure of Nitze, in which the illuminating lamp is 
introduced within the bladder, and to add to its effectiveness the 
image is magnified, renders the investigation more satisfactory. 
The bladder is distended with water or air, preferably the former, 
when the entire cavity can be carefully inspected. The elec- 
tric illumination can be obtained through a transmitter from 



PELVIC EXAMINATION. 



95 



the street current or the dry cell battery may be employed. An 
instrument not larger than a No. 30 bougie, French scale, is 
sufficient for every purpose in the inspection of the bladder and 
■catheterization of the ureter. Such an instrument may be em- 
ployed without an anesthetic ; the bladder may be irrigated and 




Fig. 59. — Kelly's Specula (Urethra), 





Fig. 60. — Mouse-tooth Forceps for Cotton Pledgets. 




Fig. 61, — Kelly's Evacuator. 



Figs. 62 and 62,. — Ureteral Catheters — Metal and Soft. 

filled through the tube, after which its escape is perfected by 
the introduction of a magnifying lens. The cystoscopic inspec- 
tion is of value, as it discloses the condition of the vesical mucous 
membrane, permits the differentiation of desquamation and 
catarrh from gonorrheal and tubercular cystitis, and has demon- 



96 



GYNECOLOGY. 



strated the dependence of obstinate cystitis upon torpid ulcera- 
tion of the vesical mucous membrane. It permits the inspection 
of the inflamed, pouting orifices of the ureters and allows the 
determination of the affected kidney by the observation of blood 
or pus coming from the orifices of the corresponding ureter. It 
has permitted the recognition and dislodgment of calculi situ- 
ated in the lower end of the ureter. The condition of the 
ureter and kidney is also determined by passing through the 
posterior slit of the cystoscope a long, soft, ureteral catheter. 




Fig. 64. — Harris' Double Catheter for Obtaining Urine from Kidneys Separately. 

This procedure permits the exploration of the ureter and the 
accumulation of the urine for examination, affording an oppor- 
tunity to determine whether one or both kidneys are involved. 
By a wax-tipped bougie, as suggested by Kelly, the presence of 
a calculus can be recognized in the ureter or in the pelvis of the 
kidney. The segregator, as devised by Harris, of Chicago, will 
permit the accumulation of the urine from the kidneys in separate 
receptacles, but it is inferior to the use of the ureteral catheter 
through the cystoscope. 



ABDOMINAL EXAMINATION. 

159. Preliminaries. — An examination from the diaphragm 
to the pelvis should be made of every woman who presents 
symptoms which indicate that she is suffering from pelvic disease. 
Such an investigation will reveal ptoses of the abdominal viscera, 
tumors, hernia, disease of the gall-bladder or appendix, and 
other conditions which otherwise would be overlooked. The 



ABDOMINAL EXAMINATION. 



97 



patient must have her clothing so adjusted that the entire sur- 
face of the abdomen can be exposed. She should lie in the 
dorsal position, upon an examining chair, bed, or table, with 
her limbs slightly flexed. A sheet is thrown over her lower 
extremities and drawn over the symphysis, when the clothing 
is raised and her abdomen exposed. 

1 60. Inspection. — An investigation of the external surface of 
the abdomen is of great value. The linea nigra, linea striata, and 
increase of pigment about the umbilicus and lower abdomen are 
signs indicative of a previous or present pregnancy. These dis- 




Fig. 65, — Abdomen Prepared for Examination. 



colorations having once occurred are never effaced, and are conse- 
quently of significance only during a first pregnancy. The linea 
striata are red or purple, when recent ; white and glistening, when 
old. They are caused by overstretching of the skin, hence may 
result from any abdominal enlargement. Discolorations from 
blisters and counterirritants or scars from leech bites and wet-cups 
are indications of previous inflammation. The superficial abdom- 
inal veins are enlarged by any pressure upon the deeper vessels, 
and the enlargement occurs in pregnancy, in fibroid, ovarian, and 
other large tumors. The subcutaneous tissues become edema- 
tous in general dropsy and from acute abdominal inflammation. 
7 



98 GYNECOLOGY. 

The abdominal enlargement is symmetric, irregular, or nodu- 
lar ; the abdomen is flattened and broadened in ascites, narrowed 
and projecting in pregnancy, myomata, and ovarian cysts. The 
tumor is spheric, most prominent above to the right in pregnancy, 
rises abruptly, attaining the greatest prominence near the um- 
bilicus in ovarian cystomata, and is less likely to be symmetric 
in myomata. The surface of the skin is smooth and glistening 
from internal enlargement, and hangs in folds over the symphysis 
in obesity. A very dependent mass may be due to the protrusion 
of a large tumor between the separated recti muscles, or to a des- 
moid tumor of the abdominal walls. A large projection from the 
median line may be caused by a ventral hernia. Frequently the 
movements and outlines of the intestinal coils may be recognized. 
Fetal movements, contraction of muscles, and peristaltic action 
of the intestines can often be seen. Enlargements in the upper 
abdomen are due to growths in the liver, distention of the gall- 
bladder, enlargement of the kidney, or malignant disease of the 
ascending or transverse colon. In the median line the liver, 
stomach, pancreas, or transverse colon may be the seat of origin. 
Above, upon the left side, it may be the spleen, the left lobe of 
the liver, the cardiac end of the stomach, or the left kidney; and 
below, the descending colon. Ptosis of the stomach and liver 
can frequently be recognized. In the lower abdomen the genital 
organs are the seat of the majority of abnormal growths. A tu- 
mor in the right inguinal region should always awaken a suspicion 
of appendiceal inflammation or malignant disease of the colon. 

i6i. Palpation. — Palpation may be practised during the exer- 
cise of the preceding step. It consists in placing the hands, pre- 
viously warmed, upon the bare abdomen, and gently moving 
them from side to side, now close together, or again bringing the 
entire abdomen between their grasp. The tips of the fingers or 
the entire hand may be applied. Palpation enables us to recog- 
nize the presence of an abnormal growth: its situation, mobility, 
density, and relation to the abdominal viscera. Its dimensions, 
smoothness or irregularity, are recognized by carefully outlining 
the tumor. The relations and mobility of the growth are deter- 
mined by changing the position of the patient. 

The patient generally should be placed upon her back, with 
the limbs flexed and the head and shoulders slightly elevated. 
The confidence and cooperation of the patient must be obtained 
in order to secure relaxation of the muscles. It is necessary to 
proceed with the utmost consideration and gentleness, as rough, 
hasty, and inconsiderate palpation causes muscular rigidity and 
defeats the object. Pelvic abnormalities may require vaginal 
touch in conjunction with palpation, which has already been 
discussed under the bimanual examination. (Section 69.) 



ABDOMINAL EXAMINATION. 99 

162. Difficulties. — Information may be difficult to secure 
by palpation because of a large deposit of fat in the abdominal 
walls or rigidity of the muscles from fear or actual tenderness. 
The patient can in general be so reassured as to permit the in- 
vestigation to be satisfactorily accomplished. In inflammatory 
collections it is often necessary to exercise care in the procedure 
to avoid rupture of the mass and the escape of its contents into 
the peritoneal cavity. 

163. Percussion, though described separately, may be prac- 
tised in conjunction with the two preceding steps. It consists in 
eliciting resonance or dulness by mediate or immediate percus- 
sion. Fluctuation is recognized by placing a hand upon one side 
and striking upon the abdomen, more or less remotely, with the 
finger-tips of the other. A long wave indicates that the fluid is 
free or contained in a large sac. A short or indistinct w^ave is 
produced by fluid contained in a sac with numerous partitions or 
septa. The chief value of percussion is in determining solid or 
fluid tumors from distentions of the abdomen by gas or ascites. 

The ability to elicit resonance and dulness is utilized in the 
diagnosis between free fluid within the abdomen and that con- 
tained within a cyst. In the former a zone of resonance is 
elicited over the summit of the distention, while the remainder 
of the surface will be dull. The zone of resonance changes with 
the position of the patient, while in a cyst there is dulness over 
its surface and resonance above, and generally upon one side. 
In the latter the relative outline of the zones of resonance and 
dulness do not vary with change of position. The solid or cystic 
tumor, as it increases in size, pushes the viscera upward and to 
the opposite side; hence the situation of the zone of resonance. 
Resonance at the summit of the swelling in ascites is due to gas 
in the intestines, floating them to the surface. Should the 
mesentery be too short, from inflammation or great abdominal 
distention, to reach the surface, percussion gives dulness; while 
deeper pressure displaces the intervening layer of fluid, and again 
affords resonance. In localized peritoneal accumulations percus- 
sion aids only in defining their boundaries, and presents the sen- 
sation of fluctuation. 

164. Auscultation is practised directly by placing the ear over 
the abdomen, Avith a towel or sheet intervening; and, indirectly, 
through the medium of a stethoscope. The former enables the 
physician rapidly to find the sound, the latter to study it 
minutely. Auscultation is of limited application. It enables us 
to hear the fetal heart-sounds, the bruit produced by the rush of 
blood through the uterine sinuses, and various sounds induced by 
gas and liquids in the intestines. The fetal heart-sounds are 
characteristic of pregnancy ; the bruit is heard in pregnancy and 

tofa 



100 GYNECOLOGY. 

fibroid tumors alike. Efforts have been made to diagnose the 
seat of intestinal obstruction by the gurgling noise in the intes- 
tines, but our knowledge of the normal sounds is not sufficiently 
definite to enable us to make it of much value. 

165. Exploratory Puncture. — Exploratory operations for the 
purpose of diagnosis may be one of two classes: puncture and 
incision. Puncture is divided into two procedures : tapping and 
aspiration. The former is applicable to the diagnosis and treat- 
ment of ascites ; the latter, where it is desirable to lessen the size 
or to determine the contents of a cyst. 

166. Tapping, or paracentesis abdominis, was at one time the 
only method of treating abdominal collections of fluid, whether 
free or confined within a cyst. The instruments used should 
consist of a trocar and cannula, about J of an inch in diameter, to 
which a rubber tube may be attached. If Wells' blunt cannula 
is used, a bistoury must be employed to make the incision. The 
patient is placed upon her side near the edge of the bed ; a point 
is selected in the median line, about midway between umbilicus 
and symphysis, which percussion has demonstrated to be free 
from intestine ; and the surface is frozen by the application of ice 



iiMiMMiis^^^atii 




Fig. 66. — Nest of Trocars. 

and salt or a spray of ethyl chlorid. An incision is made through 
the skin, and the trocar is plunged, by a quick, rotating thrust, 
into the peritoneal cavity. The finger is held upon the instru- 
ment to govern the distance it is to be introduced. The trocar is 
withdrawn and a rubber tube is applied to the cannula to convey 
the fluid into a receptacle. The complete evacuation of the fluid 
is secured by pressing upon the abdomen toward the cannula. 
Arrest of the flow by the intestines floating against the end of 
the cannula can be obviated by changing its position. As the 
contents are evacuated the entrance of air into the abdomen may 
be prevented by keeping the end of the rubber tube submerged. 
The cannula is withdrawn and a piece of aseptic gauze is placed 
over the opening and held by a small strip of plaster. The 
withdrawal of a large quantity of liquid is frequently followed by 
symptoms of syncope. The patient should be kept in the 
horizontal position, and, if necessary, given whisky or brandy 
(fSj), spt. ammon. aromat. foj, well diluted, per oram, strychnin 
sulphate (gr. -^-^ to 3-^), atropin sulphate (gr. yio-), hypodermically, 
hypodermic injections of an aseptic ergot, or inhalations of a few 
drops of amyl nitrite. 



ABDOMINAL EXAMINATION. 



101 



167. Aspiration should be the procedure chosen when it is 
desired to evacuate the contents of a cyst. The use of the trocar 
favors the entrance of air and of pathogenic germs, and its open- 
ing permits the escape of the cyst-contents into the peritoneal 
cavity, which not infrequently promotes the development of peri- 
tonitis. The contents of a cyst should consequently be entirely 
removed if the wall has been perforated. The use of the hy- 
podermic syringe for the withdrawal of a small quantity of fluid 
for examination is reprehensible. The patient encounters a 
greater risk from the escape of a portion of the contents of a 
tense cyst through even a small opening than can be compen- 
sated by any advantage derived from an examination of the 
fluid. For aspiration two instruments may be used, one of which 
will hold a few ounces, in which the needle is connected with 
the reservoir; the other, used in large accumulations, consists 
of a large air-pump connected by 
tubing with a needle, a quart bottle 
intervening. (Fig. 67.) Rapid suc- 
tion exhausts the air in the bottle 
and causes the fluid to run until the 
cyst is emptied or the bottle filled. 
Strong suction w^hen the cyst is 
nearly empty draws its sides into the 
needle and stops the flow. The with- - 
drawal of the contents of the cyst is 
an advisable procedure when the 
pressure of the tumor is so great as to 
obstruct the circulation and lead to 
dyspnea, decreased renal secretion, 
and more or less anasarca. The 
operation in such cases, by facilitat- 
ing restoration of secretion, promotes a favorable result in subse- 
quent removal of the cyst. The procedure may be necessary, also, 
to prolong the life of the patient until a skilled operator can be 
secured. Broad-ligament cysts are occasionally cured by aspiration. 
It affords an opportunity to clear up the diagnosis in otherwise 
obscure cases. Two conditions particularly can be determined 
by microscopic examination of the fluids. Hydatid disease is 
recognized by finding even a single booklet. Malignant disease 
is determined by finding the presence of blood-corpuscles or 
particles of malignant tissue. The blood is mixed with the fluid. 
To examine it, the fluid should be drawn into a clean vessel, 
covered, and permitted to stand for twelve hours, when the 
blood-corpuscles will be found at the bottom or adherent to the 
sides of the vessel. Tapping and aspiration should always be 
done through the abdominal walls, never through the vagina or 



^ 

^ 


& 


\ 


fi 


\ It 2 ^ '"" '■' 


a 


1 


^ 1 


1 


I 


1, 


- 


1 \J 


^ 


&ji 


pr 





Fig. 67. — Aspirator. 



102 GYNECOLOGY. 

rectum, on account of the more difficult antisepsis and consequent 
greater danger of infection. 

1 68. Exploratory incision in cases of difficult or doubtful 
diagnosis is a most effective method for making known the con- 
dition, but should be very infrequently practised. The more 
carefully the sense of touch is cultivated, the less frequently will 
an incision be required. The position of a patient who has 
nerved herself to undergo an abdominal operation, only to ascer- 
tain that her trial and suffering have been without avail, is most 
distressing, and is not calculated to lead the surgeon frequently 
to repeat it in cases of extremely doubtful character. 



THERAPEUTICS. 

169. Classification. — Gynecologic therapeutics may be divided 
into general and local, medical and surgical, and the time will 
not be misemployed if we consider the subject from the stand- 
point of preventive and curative. 

170. Extension. — A cursory consideration renders it evident 
that the capable gynecologist must be versed in general medicine, 
and must be able to distinguish affections of the genital organs 
from disturbances of other organs and to recognize the indica- 
tions and contraindications for special methods of procedure. 

171. Infection. — We need but to review the consideration of 
micro-organisms presented under diagnosis to appreciate the im- 
portance of combating infection in its various manifestations. 
Not infrequently deaths following operations are attributed ta 
heart failure, shock, pyelonephrosis, and pneumonia, when they 
are without question due to infection. Infection is more likely 
to reach a wound from unclean hands or instruments than 
through the atmosphere. 

172. Terms. — The study of such conditions has originated 
the terms sepsis, antisepsis, and asepsis. Sepsis, of course, in- 
dicates the existence or sequela of infection; antisepsis, the use 
of agents which are either destructive to bacteria or hinder their 
baneful influence. Asepsis comprises the exercise of such means 
as shall exclude from the field of operation all pathogenic germs 
and their products. The latter is the ideal procedure, but when 
we have to deal with agents so intangible that it requires a micro- 
scope to discover their presence, and when it is absolutely im- 
possible to preserve aseptic or sterile ever^^hing that may come 
in contact with the affected tissues, a combination of the two 
methods seems the wiser plan of procedure. 

Sterilization means the entire destruction or removal of 
germs. Complete sterilization of everything is an ideal asepsis. 



THERAPEUTICS. 



103 



173. Sterilization Methods. — The most effective agent for 
sterilization is the flame, but this can rarely be used because of 
its destructive influence upon the temper of instruments. It is 
employed to destroy worthless and dangerous objects, such as 
soiled dressings. 

Heat may be employed in the dry and moist forms. The 
vegetative bacteria are destroyed by comparatively low tem- 
peratures, from 106° F. to 150° F. The spore-bearing bacilli 
require a higher temperature and stronger chemical solutions. 

Sterilization by dry heat is infrequently employed, for the 
reason that a temperature of 284° F. for three hours is required to 
insure the destruction of 
the spore-producing micro- 
organisms (Robb). It is 
rendered unavailable, not 
only by the time required, 
but it is injurious to in- 
struments and destruc- 
tive to ligatures and dress- 
ings. 

An effective and easy 
method of sterilization is 
by the use of steam, which 
requires an apparatus from 
which the air can be ex- 
pelled and the temperature 
maintained evenly at 212° 
F. A convenient and cheap 
apparatus for this purpose 
is an Arnold copper steril- 
izer. (Fig. 68). The most 
effective sterilization is 
accomplished in a steril- 
izer which employs super- 
heated steam under pressure. Steam at a temperature of 220° 
to 230° F. at a pressure of 15° insures the sterilization of large 
packages, but to prevent reinfection the sterilized packages 
should be thoroughly dry before removal from the sterilizer. 
The sterilizing apparatus is usually so constructed that steam 
can be turned out of the central chamber into the surrounding 
jacket and thus insure the drying of the contents of the chamber. 
Ligatures and sutures may also be sterilized in the same way, 
but much more effectively by boiling. Silk will not stand long 
or repeated boiling without becoming friable. The towels, 
sheets, and operating gowns should be subjected to what is 
called the fractional method. This consists in placing the 




-Arnold Steam Sterilizer, 



104 



GYNECOLOGY. 




Fig. 69. — Steam-pres- 
sure Sterilizer. 



material in the sterilizer for one hour the first, and one-half 
hour each succeeding, day for two days. They should be care- 
fully protected until used._ When dry and properly protected, 
they will remain aseptic for an indefinite time. 

174. Sterilization of Instruments. — The instruments for ex- 
amination and operation should be capable 
of being thoroughly cleaned, and after every 
operation should be cleansed in hot water 
and boiled before the next operation. They 
should be placed in trays dry, or upon a 
sterile table. It was formerly the custom to 
place instruments in a five per cent, solu- 
tion of carbolic acid. If the instruments 
are properly cleansed, the use of this agent 
is unnecessary, and in many operative pro- 
cedures, particularly those upon the peri- 
toneal cavity, it is objectionable, in that it 
causes irritation of the delicate structure of 
the peritoneum. The instruments should 
be sterilized before beginning an operation. 
Davidson says five minutes' boiling in water 
destroys all germs, but if the instruments 
have been used in pus or about gangrenous 
cases it is important that we should exercise still further precau- 
tions to render them absolutely sterile. They may be boiled for 
half an hour in a five per cent, solution of carbolic acid. The 
water should be boihng before the instruments are placed within 
it or they will rust. Rust- 
ing can be prevented by 
using a one per cent, solu- 
tion of carbonate of soda. 
This method of procedure 
affords a ready means of 
sterilizing an instrument 
which has been dropped 
during an operation. It 
has the advantage that any 
vessel can be used. The in- 
strument trays — preferably 
of glass or porcelain, as be- 
ing most readily disinfected 
— should be sterilized by 

heat, or, after careful washing with soap and hot water, should 
be filled to the brim with i : 500 solution of bichlorid. Trays 
should be emptied and washed out with plain sterilized water 
before the instruments are placed in them. 




Fi?. 



70.- 



-Sterilizer for Boiling- Instruments. 



THERAPEUTICS. 105 

175. Sponges. — sponges require more care and attention 
than any other part of the operation. I formerly used gauze 
pads made by taking a yard of gauze and folding it six or eight 
times, so that it made a pad from six to eight inches square. All 
selvage edges were turned in and whipped over by continuous 
suture. These pads were boiled for half an hour, dried, and kept 
in sterile vessels ready for use. They were again boiled im- 
mediately before the operation. They were inexpensive, and, 
therefore, could be thrown away after each operation. The 
majority of operators now use dry gauze for sponges: pieces of 
gauze a yard in length are so folded that the raw edges are not 
■exposed. They are done up in packages or placed in a metal 
receptacle so arranged that steam will pass through them, and 
are subjected to sterilization by the fractional method. They 
should be kept protected from dampness or any possible source 
of infection until used. The person who dispenses them at the 
operation should only handle them with a sterilized metal in- 
strument. The greatest care must 

be exercised to make certain that pp^pii^ipii^^^^i 

all pieces of gauze are accounted f^^'^^''^'^^^^^^^''''^"^'^^'^^'^- 

for before closing the abdominal ■!__ IIm 

cavity. It is advisable to assign to" I ip^ 

two persons to the sponges. One Mh. A|P: 

gives them out, and as she does so ^1 '^^'fi 

counts them. The second person ^^fc:.:, :^i:-t 14^=;==^^ 

accumulates and counts the sponges ^^^^SUmm^^^^^^^^^^^^^^^ ^^^^ 
after removal from the wound. Fig. 71.— Gauze Pads. 

The tally of sponges issued and re- 
ceived should agree before the wound is closed or the operator 
should satisfy himself by very careful examination that none 
are retained. An aseptic sponge may be retained without 
delaying the healing of the wound and become encysted, but 
later may form an abscess and open externally into the vagina, 
bladder, or rectum. Occasionally a large vessel may be eroded 
and a fatal internal hemorrhage occur. When the operator is to 
depend upon uncertain assistants, it is better to return to smaller 
pieces of gauze, which can be washed and used over and over 
during the operation. When the operator prefers sponges, a 
good, fine, tough Turkish sponge should be chosen, using a definite 
number each of round and flat sponges. They should be care- 
fully cleansed by being placed in a towel or bag and pounded 
with a cane until as much as possible of the dust and sand 
is removed. Then they are placed in water acidulated with 
muriatic acid sufficient to give a strong acid taste, in which 
they remain for twelve hours. This dissolves out the sand 
and earth. The sponges are then washed in green soap through 



106 GYNECOLOGY. 

a number of waters until they become perfectly clean, after 
which they are placed in a five per cent, solution of carbolic 
acid. A good plan of procedure in cleansing sponges is to 
place them in a solution of hyposulphite of soda — a pound of the 
salt to a gallon of water for each dozen sponges. Add to this an 
ounce of muriatic acid or half a pound of oxalic acid. The addition 
of the acid to the soda results in a double decomposition, in which 
sulphurous acid and sulphur are set free. The acid burns out 
the organic material in the sponge and at the same time bleaches 
it. Sponges should not be permitted to remain in this solution 
longer than from five to ten minutes. They are then washed 
in water until there is no longer any whitening of the water with 
the sulphur. They may then be placed in a five per cent, solu- 
tion of carbolic acid. When the sponges have been used, they 
may be washed and used again, unless they have been soiled by 
contact with some special poison or infectious material, when 
they should be thrown away. In recleansing the sponges they 
should first be washed in cold water to remove the blood, then 
soaked in a solution of washing soda, half a pound to the gallon, 
and afterward in a solution of hyposulphite of soda and oxalic 
acid. The solution in w^hich the sponges are kept should be 
changed every two or three weeks. The marine sponge is now 
rarely used because of the difficulty in maintaining it in an 
aseptic condition. The dry sterile gauze is almost as effective for 
drying a bleeding surface. It can be kept sterile and is much 
cheaper, so there is no temptation to reemploy it. 

176. Ligature and Suture Material. — Methods for Its Prep- 
aration and Preservation. — The material used by the majority of 
operators is silk. Pozzi recommends that it shall be boiled with 
carbolic acid, 50 : 1000, wound upon glass reels, and kept in this 
solution, which should be changed every week. Not too large a 
quantity should be prepared at a time, as the nearer to the opera- 
tion, the less irritating it is. Hegar uses iodoform silk, which is 
immersed twenty-four hours in iodoform 20 grams, ether 200 
grams. This is dried, wound upon bobbins, and kept in glass 
boxes. Silk may also be boiled in a sublimate solution (i : 1000). 
Nilson recommends that suture material for superficial stitches 
should be boiled in wax and carbolic acid, as it is thus less likely 
to become infected. Apropos of this method, I used a suture of 
this kind in closing the lacerated perineum of a patient immedi- 
ately following labor. Sutures were removed a week later. Tw^o 
years subsequently, during examination of this patient, I noticed 
a dark speck or groove upon the perineum, and on closer in- 
spection found it to be a ligature that had not been removed. 
It was raised up, cut, and withdrawn, when it was found that it 
occupied a groove, which was completely cicatrized and ap- 



THERAPEUTICS. 107 

parent ly was not irritated. The possibility of infection of silk 
when used upon the stump of a suppurating tube, or in a pelvic 
cavity when suppuration is present, and the long-continued sinus 
that results until the ligature itself has discharged, have led me 
to prefer some material for ligation that is more certain to be 
absorbed and will not remain in the tissues so long. I have had 
occasion to open a sinus and remove a large ligature from a 
patient upon whom the operation had been done four years be- 
fore, and the abscess did not form for three and one-half years. 
Consequently, for some time I have used nothing but catgut for 
ligatures and internal sutures. This material, when carefully 
prepared, is perfectly safe, and we have no reason to feel that the 
patient will experience inconvenience after convalescence occurs. 
Patients in whom no suppuration has occurred, nor sinus resulted, 
have subsequently suffered from pressure upon the nerve-fibers 
by an encysted ligature, requiring reoperation a year or more 
later for removal of the ligature in order to secure relief. Catgut 
for ligature is prepared as follows: No. oo, No. o, and No. 2 cat- 
gut, as obtained from the shops in long pieces, is placed in ether 
or benzin for a number of days, or even weeks, to extract the fat. 
It is removed from this and tightly wrapped upon wooden blocks 
or glass tumblers, and placed for thirty hours in a solution of 
dichromate of potash : 

R . Potassii dichromat., 1.5 

Acid, carbolic, 



Glycerin, / ' ^^ ^°-° 

Aqua 480.0 

The dichromate is dissolved in the water, and the carbolic acid 
and glycerin are added. 

The previous fixing of the gut before its immersion in the 
solution is very important, as it otherwise becomes hopelessly 
twisted and entangled. After removal from the solution the 
strands should be wTapped upon previously prepared boards 
about a meter long, and while so wrapped they should be care- 
fully dried. From these boards it is cut in meter lengths, and 
the pieces are tightly wrapped upon glass drainage-tubes. Each 
tube contains two pieces of gut. These tubes are placed in a 
1 : 1000 solution of sublimate in water for eight hours. This 
solution is poured off and replaced by a i : 500 solution of sub- 
limate in alcohol (90 per cent.), in which the catgut remains 
for twenty-four hours. From this solution the tubes are lifted 
by sterile forceps into absolute alcohol, to each half pint of which 
one dram of sterile glycerin has been added. The tubes are 
removed from this solution for use. Any unused catgut after 
an operation is not replaced. 

The No. 2 gut is employed for ligatures, the No. 00 and No. o 



108 GYNECOLOGY. 

for sutures. Gut so prepared is, in my experience, unirritating, 
and a satisfactory materiai for ligatures and sutures. 

When it is not desired to harden the catgut or there is no 
need for its remaining in the tissues for such a length of time, 
the solution of dichromate of potash may be omitted. Boeckman 
suggests the following method of rendering the catgut safe for 
use. The gut, after being cleansed in ether, hardened if desired, 
and thoroughly dried, is cut into desirable lengths, wrapped in 
waxed paper, sealed in small envelopes, and subjected to a tem- 
perature of a little above 284° F. for four hours. Pus-forming 
germs are destroyed at lower temperatures, but spore -bearing 
germs, as anthrax, so common in the intestine of the sheep, are 
killed only at the higher temperature. The envelopes remain 
unbroken until the catgut is desired for use. A number of 
manufacturers now put up catgut in alcohol or chloroform, 
sealed in glass tubes, in which it is kept free from contamination 
until desired for use. It is thus prepared plain or chromicized. 
By some it is marked 10-, 20-, and 40-day catgut, but experience 
has taught me not to place reliance upon such promises. In the 
acid secretion of the vagina none of it is likely to last more than 
ten days or two weeks. Silkworm-gut forms an excellent suture, 
is clean, not readily infected, and is easily taken care of. It may 
be boiled for ten minutes prior to the operation. 

177. Dressings. — Gauze medicated with various germicidal 
or inhibitory agents has been advocated, but it does not present 
any advantages over the sterilized gauze. The latter is non- 
irritating, and serves every purpose. It should be sterilized by 
subjecting it to steam, the fractional method, of course, being 
employed. It should be sterilized one hour the first day, the 
second day half an hour, and the third day the same length of 
time, then dried in a hot oven and placed in a closed vessel, and 
kept carefully wrapped until it is used. 

178. Operator and Assistants. — Personal cleanliness should 
be a matter of conscience. A person with nasal catarrh or bad 
breath from decayed teeth or foul stomach is disqualified to be 
either an operator or assistant. This is particularly true in 
peritoneal operations. Even the slightest examination should 
not be undertaken unless the hands and nails are carefully 
cleansed, in order to insure against the introduction of infectious 
material, and in every operative procedure the hands and arms 
should be scrubbed with soap and hot water, giving thorough 
attention to the condition of the nails. The longer the hands are 
scrubbed with soap and water, the less active are the germs that 
inhabit the surface beneath the finger-nails. After thorough 
washing with soap and hot water, the nails should be scraped and 
the washing again repeated. The fingers, and especially about 



THERAPEUTICS. 109 

the nails, should be scrubbed with a piece of sterile gauze wet 
with a 1 : 500 solution of bichlorid in 70 per cent, of alcohol, and 
subsequently washed in sterile water. Probably still better is a 
solution suggested by Charles Harrington, of Boston, which con- 
sists of commercial alcohol (94 per cent.), 640 c.c. ; hydrochloric 
acid, 60 c.c; water, 300 c.c; corrosive sublimate, 0.8 gram, 
in which the hands and arms should be bathed for thirty seconds 
to a minute after having previously thoroughly washed them with 
sterile soap and hot water. I have used this solution for the 
last year and a half with very gratifying results. Nurses and 
assistants who are to take part in the operation and handle 
sponges or dressings should be required to exercise rigidly the 
same precautions, and should be taught the importance of care- 
fully avoiding contact with any nondisinfected article; and if 
they should accidentally touch a door, basin, clothing, the face, 
or any nonsterile object, they should again scrupulously cleanse 
their hands before coming in contact with dressings or instru- 
ments. Kelly advocates, subsequent to scrubbing the hands in 
soap and hot water, that they should be placed in a solution of 
permanganate of potash (4: 1000), and this stain removed by 
washing in a concentrated solution of oxalic acid, then in lime- 
water, and finally in sterile water. Furbringer suggested that 
the hands and arms should first be washed with soap and hot 
water, then with bichlorid, preferably the acid solution, subse- 
quently with alcohol at 90 per cent. An effective method of 
cleansing the hands is to wash them with equal parts of sodium 
carbonate and calcium chlorid to which water is gradually added. 
The chlorin set free is the effective agent. There are but few 
persons, however, whose hands will endure the employment of 
this method of cleansing several times daily. Before examining 
a case of cancer w^here there is considerable decomposing material, 
it is well to anoint the fingers with turpentine, and then with 
vaselin, as in this way the disagreeable odor is more readily re- 
moved from the fingers. It Avould be better for the operator to 
wear rubber gloves or draw a condom over two fingers before 
examining cases of cancer or other infectious cases. The im- 
possibility of rendering the hands absolutely sterile, the varying 
susceptibility of different individuals to the influence of infectious 
germs, makes the habitual wearing of rubber gloves a prudent 
policy. Certainly, surgeons engaged in general surgical practice 
would do wisely to wear rubber gloves when operating within 
the peritoneal cavity. GloA^es should always be worn when the 
operator has recently examined or operated upon patients who 
were suffering from some infectious disease. 

179. Precautions. — During the progress of an operation the 
operator should have, conveniently situated, two vessels, one 



110 GYNECOLOGY. 

containing a solution of i : looo acid sublimate, and the second 
sterile water, into which he can occasionally dip his hands. 
In operations within the abdomen it is better that the bichlorid 
should be removed by sterile water. He should wxar clean linen 
and should have his clothing entirely covered by a sterilized 
apron. When there is much fluid, as in plastic operations on the 
vagina, in which continued irrigation is practised, the clothing 
should be covered with some waterproof material beneath the 
apron. Where conditions will permit, it is better that the surgeon 
should make a complete change of attire, both in the interests 
of his own health and for the safety of his patient. 

1 80. Room and Environment. — The room and surroundings 
of the patient should receive careful consideration. The room 
should be well lighted and ventilated and thoroughly cleaned; 
be free from matting, hangings, and everything that is likely to 
retain dust; in fact, no more furniture should remain in the room 
than is absolutely necessary. The operating room should be one 
whose walls can be thoroughly washed and carefully cleansed; 
its furniture should be made of metal and glass. When the opera- 
tion is to be performed in a dwelling, the room should be carefully 
scrubbed with a carbolic-acid solution (50: 1000) two days in 
advance. In a private house where the rooms are old or their 
condition at all suspicious, they should be disinfected with a 
formaldehyd apparatus. It was formerly the practice to operate 
under the carbolic acid spray, but it was found to have a pre- 
judicial influence upon the peritoneum. Until quite recently 
some operators still kept a spray in the room for the moisture 
and to secure the beneficial influence of the carbolic acid, but 
the drug is so disagreeable and injurious to many patients that 
the practice has been discontinued. Sterilized water should be 
at hand in carefully covered vessels, and when antiseptic solu- 
tions are used, they should be designated so that no mistake can 
be made. 

181. Examination and Preparation of Patient. — An examina- 
tion should be made of the urine, as to its specific gravity, 
quantity of urea, presence or absence of albumin or sugar, 
approximate quantity of solids, and where the conditions in- 
dicate it, the -microscope should be employed. A fair estimate 
of the amount of solids may be obtained by Haine's modification 
of Haeser's method, viz. : ' ' Multiply the last two figures of the 
specific gravity by the number of ounces of urine passed in 
twenty-four hours, and this product by one and one-tenth." 
This estimate includes urea and all other solids. The quantity 
will depend upon the avoirdupois of the patient. Etheridge 
has prepared the following table: 





THERAPEUTICS. 






Weight. 


Urinary Solids. 


Weight. 




Urinary Solids. 


90 pounds 

TOO " 

no " 
120 " 
130 " 


789 grains 
854 " 
916 

974 " 
1028 " 


140 poun 

160 
170 
180 


ds 


1078 grains 
1150 
1198 
1237 " 
1260 " 



111 



The performance of the respective functions of the heart and 
lungs should be investigated. Frequently an examination of 
the blood will be of service. While a low percentage of hemo- 
globin does not preclude operation (as I have performed a 
hysterectomy upon a patient with recovery in whom the hemo- 
globin was only 20 per cent.), it has, however, an important in- 
fluence upon the healing of wounds and the convalescence of the 
patient. A careful blood examination is valuable, therefore, 
in the prognosis of operative conditions associated with anemia. 
The bowels should be thoroughly evacuated; this is particularly 
important when a plastic operation is to be performed upon the 
rectovaginal septum. The diet should be regulated according 
to the proposed operation. In peritoneal and intestinal opera- 
tions milk and other foods containing much waste should be 
excluded. 

A thorough evacuation of the bowels should be secured by 
the administration of half an ounce of Rochelle or Epsom salts, 
or two drams compound licorice powder, or half a bottle of 
magnesium citrate two nights previous to and the morning 
preceding the day set for the operation. A large rectal enema 
of soapsuds should be given the preceding night. The patient 
should be kept in bed for twenty-four hours prior to a serious 
operation. She should be given a general bath twice daily for 
two days, with special attention to washing the external genitals, 
the anus, and the depression of the umbilicus. Vaginal ir- 
rigation with 1 : 2000 sublimate solution should accompany each 
bath. The abdomen and genitalia should be shaved the evening 
before the operation and the abdomen should be washed with 
tincture of green soap and hot water, the flesh-brush being 
diligently applied. If the patient is uncleanly or the skin is oily, 
the surface should be washed with ether, then with soap and 
water, and finally with a (i : 1000) sublimate solution. This 
washing should be repeated on the morning of the operation, 
and the abdomen should then be covered with a pad saturated 
with sublimate solution, which should be retained by a bandage, 
to be removed when upon the operating table. In all cases it is 
desirable that the field of operation should be again thoroughly 
scrubbed after the administration of an anesthetic, with soap and 
hot water, the superfluous soap being removed with alcohol. 

182. Special Preparation. — Vaginal Operation. — The first step 
should consist in a careful cleansing of the vagina. For this 



112 GYNECOLOGY. 

purpose a combination of creolin with green soap is very effectual, 
using creolin, one or two drams, green soap, one or two ounces, to 
the quart of hot water. The vaginal canal should be thoroughly 
scrubbed with this solution, introducing two fingers wrapped 
with gauze. This procedure will remove all debris which may 
have lodged in the crypts and folds of the vagina. The solution 
should be removed by washing with sterilized water and then 
with alcohol. Creolin is not so effective an agent in sterilizing 
the vagina as the acid sublimate solution, but it has the advantage 
that it leaves the vagina soft and flexible, which is an important 
consideration in obstetrics as well as in all operative procedures 
upon the vagina. The bichlorid and carbolic-acid solutions, 
on the other hand, have a const ringing eft'ect upon the vagina, 
which renders it less elastic. 

183. Irrigating Tubes. — All the cannulas used for the purpose 
of cleansing the vagina should be made of glass (Fig. 72), as they 
are more readily cleansed, are less likely to contain infectious 
material, and are sufficiently cheap to permit them to be thrown 
away when used in suspicious cases. If injections are used by 



Fig. 72. — Irrigating Glass Tube. Open End. 

the patient, there should be no central opening of the nozle, for 
the reason that it may be introduced directly into a patulous 
cervical canal, and fluid thrown with force into the cavity results 
in severe uterine colic. Indeed, fluids have been thrown into 
the uterus and forced by uterine contraction through the tubes, 
which caused serious, if not fatal, pelvic inflammation. There 
is no special advantage in having a curved cannula or tube for 
irrigation. The nozle used by the physician in an operation 
should have but a single orifice, and that should be a central one. 
After irrigation has been practised, pressure should be made 
upon the fourchet, to insure the entire escape of fluid. It is 
sometimes advised that the irrigation should follow the ex- 
amination or operation, but we can not too strongly impress 
upon the student the fact that the genital canal sometimes con- 
tains dangerous germs, and that antisepsis must precede as well as 
follow an operation. In cancer or sloughing fibroids we may, 
in addition to the ordinary disinfection, require the use of de- 
odorizing agents. For this purpose a three to five per cent, 
solution of thymol or two or three tablespoonfuls of Labarraque's 
solution to the quart of water may be used. 



THERAPEUTICS. 113 

184. Gauze. — iVfter the uterus and vagina are carefully 
cleansed, the canal can be packed, if preferred, with iodoform or 
other antiseptic gauze which will remain sweet for a number of 
days. Iodoform is preferable to the simple sterilized gauze. To 
prepare it, ten layers of plain gauze are sterilized by boiling, pref- 
erably in a solution of carbonate of potash, washed, then soaked 
in a solution consisting of iodoform 50, glycerin 100, and ether 
700 parts, after which the gauze is passed through a wringer and 
dried in a darkened, isolated room at a temperature of 85° F. 
When dry, it is placed in tin boxes. This gauze should always 
be sterilized before its use. This can best be accomplished by 
heating it to the temperature of 250° F., by which both germs 
and their spores are destroyed. It should be remembered that 
iodoform is not a germicide. Its value is in its reductive in- 
fluence upon the ptomains and leukomains, by which their 
deleterious effects are arrested. Iodoform is poisonous to some 
patients. Sometimes it produces high temperature, irritation 
of the skin, and a smoky, darkened urine, and in others, extreme 
disturbance of the digestive tract. In such idiosyncrasies one 
of the other forms of antiseptic gauze should be preferred. These 
comprise borated, salicylated, carbolized, formalized, and acetan- 
ilid gauze. Sublimated gauze can be made by first boiling it in 
a solution of carbonate of potash (20: 1000), then an hour in a 
(i : 1000) sublimate solution, when it is dried in a sterilizing oven 
and preserved in closed glass jars. Salol and iodol are infe- 
rior in their action to iodoform. Carbolic acid is unreliable. 
Aristol, an agent that is made by the combination of thymol 
and iodin, is probably preferable to iodoform. It has the ad- 
vantage of the absence of disagreeable odor. The powder is 
very dry, not rapidly soluble, and coats over and protects the 
surface. 

185. Antisepsis of the cervix and uterine cavity is secured by 
intra-uterine injections of sublimate solution, carbolic acid, 
dioxid of hydrogen, or, preferably, formalin (1:1000). Of the 
solutions of mercury, the acid sublimate is preferable, for the 
reason that it does not form an albuminate of mercury by com- 
bination with the serum of the blood, and is less hkely to be 
absorbed and to produce a toxic effect. This agent is not so 
dangerous as in obstetrics, unless there has been a large denuded 
surface. In such cases its use should be followed by an injection 
of sterilized water. I prefer a hot i to 2 per cent, solution of 
sodium chlorid or a 2 per cent, solution of the sodium bicar- 
bonate for irrigation of the uterine cavity during or following a 
curetment. It is fully as efiicient as the stronger germicidal 
agents, and if a perforation should occur, or fluid pass through 
the tubes, this fluid will prove innocuous in the peritoneal cavity. 

8 



114 GYNECOLOGY. 

In intra-uterine injections a double catheter should be employed, 
in order that the return flow may not be obstructed. It may 
be made of hard rubber, glass, celluloid, or metal; the last- 
named are more likely to be acted upon by the mercury salts. 
If the uterine cavity is well dilated, the double tube will be 
unnecessary. ^Vfter the cavity is carefully cleansed it may be 
packed with an iodoform gauze tampon, or a pencil of iodo- 
form may be introduced. Von Hacker recommends the follow- 
ing: Iodoform, 5 drams; gum acacia, glycerin, starch, each, 30 
grains ; mix, make pencils, introduce into the cavity of the uterus. 
When these pencils give rise to uterine coHc, it may be pref- 
erable to dust the cavity with iodoform through an insufflator, 
or, still better, the use of aristol by the same means. 

In sloughing fibroids or intra-uterine cancer the cavity should 
be irrigated with an acid sublimate solution (i : 2000), followed 
either by sterilized water or a solution of chlorid of sodium (6: 
1000). In operations upon the vagina or cervix continuous 
irrigation may be practised, using for this purpose a solution of 
carbolic acid (5 : 1000), sublimate (i : 2000), formalin (i : 1000), 
or, better, chlorid of sodium (6 : 1000). The irrigation washes 
away the blood, renders unnecessary the use of sponges, and the 
surfaces are constantly kept bathed with the antiseptic fluid. 
It is the preferable procedure in all operations upon the vulva, 
vagina, and cervix. 

186. The Use of Tents.— In dilating the uterus the sponge, 
tupelo, or laminaria tents, although carefully disinfected, are not 
without danger. Pozzi recommends the latter tent, but he first 
immerses it in a saturated solution of carbolic acid and rectified 
spirits, or in a solution of iodoform and ether with a tenth part 
alcohol. In my judgment the best method of rendering the tent 
safe is to immerse a laminaria or series of such tents in the 
official tincture of iodin for a few minutes prior to its introduc- 
tion into the uterine cavity. The objection to the use of tents is 
the difficulty in previously sterilizing the uterine canal. Unless 
it is thoroughly done, as you would in the performance of any 
operation, the patient is in danger of subsequent inflammatory 
attacks. For this reason, in the majority of dilatations, I prefer 
to use the bougies and accomplish rapid dilatation in preference 
to the slower procedure with the tent. 

187. Abdominal Section. — The peritoneum is a membrane 
exceedingly susceptible to the influence of all chemic agents, and 
its delicate structure would be injured or destroyed by any agent 
of sufficient strength to have a germicidal influence ; consequently, 
our aim should be rather to procure asepsis than antisepsis. 
Assistants must be personally clean. They should have taken a 
thorough bath on the morning of the operation and should have 



THERAPEUTICS. 115 

seen no case of contagious disease prior to its performance. They 
should remove their coats and vests, bare their arms to above the 
elbows, thorough^ scrub their hands and arms with soap and hot 
water, and wash in disinfectant solutions. Their clothing should 
be covered with clean sterile linen. They should subsequently 
avoid shaking hands or touching any objects not disinfected. 
The greatest safety against infection will be secured by the opera- 
tor and his assistants wearing rubber gloves. 

1 88. Indications for Anesthesia. — The use of some anesthetic 
is necessary in the performance of many operations, and is of 
great advantage in all. In the virgin, in nervous patients, or 
those in whom the abdominal and pelvic organs are very tender 
from the presence of inflammation, the administration of an 
anesthetic renders an examination much more satisfactory to 
the physician and less distressing to the patient. 

189. Agents Employed. — In an examination it is undesir- 
able that the patient should be long under the influence of an 
anesthetic or should have a large quantity administered. Ether 
and chloroform are objectionable, first, because of the length of 
time required to secure insensibility and recover consciousness; 
second, the subsequent nausea and vomiting, which frequently 
last for hours. Nitrous oxid gas is an agent w^hich produces 
prompt unconsciousness, and from which the patient as promptly 
recovers, but it requires a special, quite expensive, and rather 
unwieldy apparatus. 

Bromid of ethyl is almost as rapid in its effects as the nitrous 
oxid, requires but a small quantity, the patient regains con- 
sciousness almost immediately after the inhalation is discon- 
tinued, and its use is much less frequently followed by nausea 
and vomiting. It can be administered in one's office, and the 
patient, shortly after return to her home, feeling but little the 
worse for her experience. This agent is very satisfactory for 
short operations, such as opening abscesses or dilatation of 
the urethra or anus. In very nervous patients it may precede 
the administration of ether or chloroform, whereby the stage of 
excitement and struggling is avoided. With the assistance of 
Dr. P. B. Bland, during 1902-03, I made some experiments with 
the chlorid of ethyl and found it to act very satisfactorily in pro- 
ducing quick anesthesia. I employed the drug for anesthesia 
in a number of serious operations. In one patient I did a 
hysterectomy under its use, the time occupied for anesthesia 
being fifty minutes, without any unpleasant symptoms. With 
a suitable inhaler it can be effectually employed with the ad- 
ministration of a very small amount of the agent. It has not 
seemed to produce any uncomfortable sensations following 
the operation, although the anesthesia is not as profound and 



116 



GYNECOLOGY. 



durable as that induced by other anesthetics.* For prolonged 



operations ether and chloroform are to 



be preferred. Eiher is 
generally recognized as 
the safer drug. In the 
very young or the aged 
it is less satisfactory 
than chloroform, and 
probably not so safe. 
Chloroform should be 
preferred in the pres- 
ence of renal disturb- 
ance and when the pa- 
tient is suffering from 
emphysema or chronic 
bronchitis. Some of 
the French surgeons 
advocate the adminis- 
tration of -J- of a gr. of 
sulphate of morphin 
and ylo- of a gr. of 
sulphate of atropin 
hypodermically about 
twenty minutes prior 
to the administration 
of chloroform, and they claim: (i) that it increases the safety by 




Fig. 



73. — White's Oxygen Apparatus, which can 
be UtiHzed for Anesthesia by Placing Anes- 
thetic in the Bottle. 




Fig. 74. — Northrup's Apparatus for Administering a Mixture of Chloroform 

and Oxygen. 



diminishing the danger of syncope; (2) that the patient is much 

* Since writing the above I have had a death from ethyl chlorid and would 
advise the greatest caution in its employment. 



THERAPEUTICS. 117 

less likely to suffer from nausea and vomiting; (3) that the 
patient, having taken a smaller amount of the vapor, recovers 
consciousness more quickly. 

Scopolamin-morphin narcosis.- — A combination of these drugs 
was advocated by Schneiderlin in 1900 as a means of rendering 
patients sufficient^ insensible to pain to permit of the per- 
formance of the various surgical procedures. Recently they 
have been extensively^ employed. Korff, who administered the 
combination in tAvo hundred cases, advised scopolamin hydro- 
bromate -^ milligram, Avith morphin sulphate 25 milligrams, 
divided into three doses, to be given hypodermically, three 
hours, one and a half hours, and half an hour before the 
operation. The first dose renders the patient drowsy, the sec- 
ond puts her to sleep, and the final one renders her insensible to 
pain. Scopolamin-morphin narcosis has been advocated as lessen- 
ing the danger of anesthesia. The employment of a combination 
of drugs, though capable of rendering the patient unconscious for 
hours, cannot be considered as free from danger, and the results 
seem to shoAv that the procedure should be avoided in persons 
AA'ith Aveak A'essels and enfeebled heart action. It has been 
claimed that the preliminary administration of y^ grain of the 
scopolamin hydrobromate AA^th -g- of a grain of morphin Avould 
enable the administrator to giA^e much less of the ordinary an- 
esthetic, and in the majority of cases the patient will be free 
from the postoperative nausea and vomiting. The experience 
of nearly one hundred cases at the Jefferson Hospital clinic has 
demonstrated that a greater number of patients haA'ing this pre- 
liminary injection will suffer from nausea and A'omiting than 
AA^hen ether is given alone. The onty adA^antage which I Avould 
concede it is that where the patient is nerA'ous and fearful of the 
operation, she is so doped before she comes to the operating room 
that she is oblivious to CA'crything and takes the anesthetic AA^th 
but little difficulty. The administration of a mixture of chloro- 
form and oxygen, obtained by passing oxygen through a bottle 
of chloroform to the inhaler, decreases the danger of this agent 
and accomplishes anesthesia with the minimum quantity of the 
drug, AAithout discomfort, AAdth lessened nausea, and AA^th slight 
subsequent distress. (Figs. 73 and 74.) The patient does not 
haA^e the blanched appearance of the face, and rapidly recoA^ers 
when its administration is suspended. I do not feel it neces- 
sary to describe the administration of the anesthetic further than 
to caution that false teeth and foreign bodies should be remoA^ed 
from the mouth. 

190. Administration. — The patient should be directed to 
breathe deeply. She should be reassured by the physician, 
both in speech and manner. Talking upon the part of the 



118 GYNECOLOGY. 

administrator or attendants should be avoided. The pulse, 
respiration, and condition of the pupil should be continually 
observed. Dilatation of pupils, blanching of the face, arrested 
or stertorous breathing, and sudden feebleness of the pulse 
should indicate the temporary withdrawal of the vapor. Con- 
tinued syncope, particularly in chloroform narcosis, requires 
resort to artificial respiration, and often suspension of the pa- 
tient with head downward. The administrator of the anes- 
thetic should be provided with a hypodermic syringe, solutions 
of strychnin and atropin, and some nitrite of amyl. The latter 
agent is of advantage because of its rapid action as a primary 
heart stimulant, and its influence in dilating the arterioles by 
its action upon the vasomotor system. When chloroform is 
largely given, a bellows and mask, by which the lungs can be 
inflated with air, will not infrequently be effective in saving 
life. In suspended respiration forcible pulling upon the tongue 
acts as a respiratory stimulant. The inhalation of vinegar 
following anesthesia appears to lessen the tendency to nausea. 

191. Local Anesthesia. — General anesthesia is attended with 
danger in renal disease, in marked pulmonary changes, in fatty 
degeneration of the heart, and in atheroma of the large vessels. 
In such cases, and when general anesthesia is objectionable, 
local anesthesia may be employed. Freezing by ice and salt, 
by ether, or by ethyl chlorid spray may be utilized, but its 
application is limited. Continuous irrigation with carbolic acid 
has a benumbing effect upon the mucous surfaces, by which 
pain is obtunded. 

Cocain. — The most effective agent for local anesthesia is 
one of the cocain salts. In operations about the genitals or 
anus it is preferably given hypodermically, and for this pur- 
pose the phenate of cocain is the most satisfactory. It is slower 
in being absorbed, and is less likely to be a source of infection 
from the presence of micro-organisms. Some have advocated 
eucain in preference to cocain, as it is less volatile and hence 
more readily sterilized. It is also less likely to cause depression. 
Stovain, a synthetic preparation, is claimed to be free from the 
depressing and toxic effects incident to cocain. The injections 
should be made with a one or two per cent, solution, using as 
much as from one to three grains of the drug. The injection pro- 
duces anesthesia for the distance of half an inch from the point of 
the needle; consequently a number of injections may be re- 
quired. This method of anesthesia has been effective in am- 
putation of the cervix, trachelorrhaphy, and operations upon 
hemorrhoids and fistula in ano. The drug sometimes has an 
alarmingly depressing effect. This symptom, it is said, may 
be avoided by combining nitroglycerin in the injection. When 



THERAPEUTICS. 119 

symptoms of depression occur, resort should be had to strychnin, 
atropin, alcohohc preparations, and nitroglycerin. 

Schleich, of Germany, after considerable experimentation, 
has suggested three solutions for infiltration anesthesia. The 
basis of all is a solution of two parts sodium chlorid, one-fourth 
part morphin hydrochlorate, in water one thousand parts, 
to which, for what is called the stronger solution, two parts 
cocain hydrochlorate are added — one part for the medium 
and one-tenth part for the weaker solution. The water and 
salt are sterilized by heat. A larger syringe than usual is used. 
The site for operation is carefully cleansed ; then, after numbing 
the surface with an ethyl chlorid spray, a puncture is made 
and fluid injected until a wheal the size of a dime is raised; 
the needle is introduced in its margin, and so continued until 
the entire length of the proposed wound is completed. The 
first puncture is the only painful one. The insensibility of 
the skin lasts for from fifteen to twenty minutes. 

Spinal anesthesia is secured by the injection of one to two 
grams of a sterilized (2 per cent.) solution of cocain into the 
spinal cavity. The injection is made between the lumbar 
vertebrae, and on a line level with the crests of the ilia. A 
long needle is introduced, the entrance of which into the spinal 
canal is indicated by the escape of spinal fluid. This form 
of anesthesia has been largely practised by Tuffler, of Paris, 
who has observed no untoward symptoms and has found it 
very satisfactory in all operations below the diaphragm. In 
a patient who had had one kidney removed and the remaining 
one so diseased as to render the employment of a general anes- 
thetic unwise, under this method I opened up a sinus which 
extended down to the vertebrae and into the pelvis without 
pain to the patient, and without the depression and horrible 
nausea which had been associated with her previous operations. 
A second patient, a young girl, had a large necrotic ovarian 
cyst, a portion of one lung consolidated, and a mitral murmur 
with beginning cardiac insufficiency — factors which made her 
condition very unfavorable for ether or chloroform narcosis; 
spinal anesthesia was employed, and I was able to remove 
the tumor without pain, and the patient had an uninterrupted 
recovery. 

192. Preliminary Details of Operation. — The presence of 
the patient, anesthetized, in the operating room presupposes 
the thorough preparation detailed in the previous paragraphs. 
A sufficient number of well-drilled assistants should have their 
duties assigned, so that the operation may proceed without 
confusion or delay. Instruments, ligatures, dressings, sterilized 
water, and sponges have been prepared. In abdominal opera- 



120 GYNECOLOGY. 

tions the number of sponges or pieces of gauze should be known, 
so that they may be accounted for before the wound is closed. It 
is also important to have a definite number of instruments, as 
both sponges and instruments, especially hemostatic forceps, 
have been left in the abdominal cavity. Every step of the opera- 
tion, to the minutest detail, should be conscientiously watched, 
for, as the chain is only as strong as its weakest link, so an 
otherwise perfect aseptic procedure may fail through a single 
flaw. I have seen the most careful preparations for an opera- 
tion, and the operator place his silk sutures upon a syringe box ; 
an assistant stroke his mustache, a nurse use her handkerchief, 
or stroke her hair, each instance being a break which imperils 
the result. 

193. Arrangement. — The instruments should be placed at 
the right of the operator, so that he can reach them as needed. 
The sponges should be in the care of a nurse upon the opposite 
side. The sponges or gauze pads should be removed from the 
receptacle and passed to the operator or his assistant by the 
nurse with a pair of forceps. After being used they should 
be placed in a basin. The nurse dispensing the sponges should 
keep an accurate account of the number given out, with which 
those returned should correspond. The wound should not be 
closed until it is certain all sponges have been removed. It is 
well to have one large, broad piece of gauze for walling off the 
intestines, or several smaller pieces may be employed and the 
end of each secured with a pair of forceps. A basin of sterilized 
hot water should be alongside the instruments for the hands 
of the operator, and his principal assistant should have another. 

194. Positions of Operator and Assistants. — In an abdom- 
inal section I prefer to stand on the patient's left, with my 
assistant opposite; the second assistant gives the anesthetic; a 
third looks after the instruments, ligatures, and sutures. One 
nurse attends to the sponges, a second changes the water in 
the basins, especially in those for the hands of the operator 
and assistant, prepares sterilized water or salt solution for 
irrigation, and counts the pads which have been used and re- 
turned, which count should tally with the one made by the 
nurse dispensing them. A third may be ready for emergency and 
have the dressings ready upon the completion of the operation. 

195. Clothing of Patient. — The patient will be better to 
have all clothing removed, in order to prevent it becoming 
soiled during the operation. Separate and clean blankets should 
be wrapped about the upper part of the body and the lower ex- 
tremities. These should be covered with sterilized towels, and 
over all a sterilized sheet, in the center of which an opening has 
been prepared for exposure of the field of operation. 



THERAPEUTICS. 



121 



196. Incision. — The linea alba is chosen for the site of in- 
cision in the majority of cases of abdominal section. A cut, 
varying in length from two to twelve inches, according to the 
condition for which the operation is done, is made with a sharp 




NURSE lATITH 
SPONGES 



Operating fwoM 

FROM ^BOVE^ 



NURSE AT 
/NSTRUMENT 
TABLE 



Fig. 75. — Arrangement of Tables and Assistants in Operating Room. 



knife. When the abdomen is moderately distended with a 
growth, the first sweep of the knife should reach the fascia 
over the peritoneum. The operator and his assistant with 



122 



GYNECOLOGY. 



long dissecting forceps pick tip the peritoneum and cut it be- 
tween them, thus avoiding injury to the cyst, or, when the 
abdomen is undistended, a knuckle of intestine. 

As soon as the peritoneum is opened, the atmospheric pres- 
sure carries the intestine out of the way, when the incision may 
be completed with a knife or with probe-pointed scissors, in- 
troducing two fingers as a guard. Should considerable bleeding 
occur after the first sweep of the knife, it can usually be con- 




Fig. 76. — Abdominal Wall Incised ; 
Peritoneum Picked up by Dis- 
secting Forceps. 



trolled by pressure with a gauze pad. AA^hen this is insufficient, 
the bleeding vessels should be seized Avith hemostatic forceps. 

The length of the incision has been a prolific source of dis- 
cussion. It has but little influence upon the result. It should 
be sufficiently long to permit the object of the operation to 
be accomplished with ease and as little irritation as possible. 
A long incision, if properly united, will be as firm as a short one. 

A combined transverse, or better, crescent-shaped and vertical 
incision, was reported at the International Congress on Obstetrics 
and Gynecology, held in Geneva in August, 1896, also described 



THERAPEUTICS. 



123 



in a paper by Kiistner in an article in September of the same year, 
and has been largely practised by Stimson and Cumston in this 
country. It consists of a crescent-shaped incision just above the 





Fig. 78. — Crescent Incision Exposing Aponeurosis. 




Fig. 79. — Aponeurosis Excised, Showing Pyramidalis Muscles. 



symphysis, and, where possible, confined to the hair surface. It 
extends through the skin, superficial fascia, and aponeurosis. 
These tissues are drawn up, separating the aponeurosis from its 



124 



GYNECOLOGY. 



attachment to the pyramidalis muscles. The rectus muscles are 
separated in the median line, and the peritoneum incised verti- 
cally. This incision permits free access to the pelvic viscera, and 
is satisfactory unless a large growth is present, which will require 
a longer incision. The advantages of the procedure are that the 
subsequent growth of the hair hides the incision ; the probability 
of hernia is lessened, as the suture closing the peritoneum and 
muscle wall is at right angles to that of the aponeurosis. The 
disadvantages are: the increased bleeding from cutting across 




Fig. 80. — Scalpels. 



vessels^and the inability ahvays to avoid the occurrence of hema- 
toma either below or above the aponeurosis. Where there is 
much disposition toward oozing, it is better to insert one or two 
small drains for the first two days. 

197. Adhesions. — In inflammation complicating a cyst it 
may be difficult to determine when we are through the perito- 
neum. In case of doubt it is better to continue the incision 
until the cyst is opened, when the line of union can be more 
readily determined. It is well to remember that at the um- 
bilicus the peri- 
toneum is closely 
united to the over- 
lying tissue, and this 
fact may be utilized 
in cases of uncer- 
tainty. As far as 
possible, separation 
of adhesions should 
take place under the eye, by drawing them down to the incision. 
Vascular adhesions and every bleeding vessel should be secured 
with forceps or should be ligated. 

With' the application of forceps the number of necessary 
ligations will be reduced, as the pressure will often prevent 
subsequent bleeding. The wound should not be closed if any 
large bleeding points are present. In short, firm intestinal adhe- 
sions the greatest safety is assured by keeping close to the cyst. 
In some cases it may be necessary to cut into the cyst, leaving a 
portion attached to the intestine, always taking the precaution. 




Fig. 81. — Pressure Forceps. 



THERAPEUTICS. 



125 



however, to remove its inner, secreting surface. Frequently the 
worst adhesions the operator wih meet are associated with infec- 
tive processes in the tubes, ovaries, or in relation to myomatous 
growths of the uterus. In both of these conditions the adhesions 
may be so firm as to require the use of the scissors for their separa- 
tion. All bleeding vessels should be secured and where possible 
the raw surfaces sutured. 

198. Toilet of the Peritoneum. — In the removal of large 
cysts care should be exercised that their contents do not escape 
into the abdomen. If the contents are uncontaminated, con- 
sisting of thin serous fluid, it should be removed by sponging 
only. It is difficult for me as an operator to get over early 
impressions. My education leads me to resort to abdominal 
irrigation, preferably with normal salt solution, whenever 
infection is possible, but experience has demonstrated that 
patients do equally well when pus is sponged out with dry gauze 
pads as when irrigated. It is a serious question whether the 
measures we often institute in the name of toilet of the perito- 
neum are not more prejudicial than helpful. When irrigation is 




Fig. 82. — Dissecting Forceps — Long Bladed. 



done, it is most effectively accomplished by pouring the belly 
full of normal salt solution, churning it about, pressing it out, 
and removing the remainder with sponges. All bleeding points 
must be secured. If there is oozing from the surface, sponges 
wrung out of hot water should be packed firmly upon it until the 
operation is completed, when they can be removed. If bleeding 
still continues, the surfaces should be sponged with a hot solution 
(10 per cent.) of ferripyrin, sprayed Avith a 4 per cent, solution 
of antipyrin, or infiltrated with a solution of one part (i : 1000) 
adrenalin chlorid to three parts sterile water. Should hemor- 
rhage be persistent, a gauze pack affords an efficient means of 
control. 

199. Drainage. — The question of drainage was formerly a 
momentous one. Keith's rule that it should be used only when 
there was something to drain was a good one, but with improved 
methods of technic we can depend more and more upon the 
natural absorptive power of the peritoneum. The employ- 
ment of the glass drainage-tube, which was formerly a matter 
of routine, is now more honored in the breach than in the ob- 
servance. When a glass drainage-tube is employed, it should 



126 



GYNECOLOGY. 



be from six to eight inches long, with a number of small perfora- 
tions at the lower extremity. These openings should be small, 
otherwise portions of intestine or omentum slip into them and 
become strangulated or render the removal of the tube pain- 
fully difficult. The openings should be smooth, and should be 

beveled at the expense of the 
outer surface. The lower end 
of the tube should be open; the 
external end should be pro- 
vided with a flange, over which 
/^— ^-3--;^- ^™^- "^^ ^^^^^^^^'^^/pl ^ piece of rubber dam may 
^^^^B^^^^^^^^^^sll J be placed to prevent soiling of 

the dressings. The caliber of 
the tube should not exceed one- 
third of an inch. The use of 
the drainage-tube required most exacting care upon the part 
of the nurse and the physician. Every precaution had to be 
exercised to prevent it becoming a gateway for the entrance of 
infection. It needed to be cleaned every half hour or oftener 




Fig. 83. — Glass Drainage-tubes. 




Fig. 84. — Uterine Syringe for Cleansing Drainage-tube. 

SO long as there was any discharge. This was accomplished 
by the use of a suction tube which reached to the bottom of 
the tube, or, better, by tube forceps and pledgets of sterilized 
absorbent cotton. By either method micro-organisms in large 
number, in spite of every precaution, found ready entrance. The 




Fig. 85. — Tube Forceps for Cotton Pledgets. 



frequent cleansing of the tube was ai^oided by passing a strip of 
sterile gauze to its bottom, which acted as a wick. 

200. Objections to Drainage. — The glass drain was objec- 
tionable because: (i) It obliged the patient to remain upon 
her back; (2) unless carefully placed it caused sufficient pres- 
sure upon the rectum to produce ulceration and even a fecal 



THERAPEUTICS. 



127 



fistula; (3) it increased the difficulty in maintaining the wound 
aseptic, and afforded ingress to pathogenic germs, either through 
its cavity or along its sides; (4) it rendered the abdomen weak 
and increased the danger of ventral hernia; (5) it endangered 
,the formation of a 
sinus which was long f^f~x 
in closing. The fre- 
quency with which 
drainage was thought 
to be required, it was 
found, could be les- 
sened by the introduc- 
tion of large quantities of normal salt solution, by which the 
infectious material was diluted and rendered more readily con- 
trolled by the peritoneum. Later experience has demonstrated 
that such cases do equally well by careful walHng-off of pus col- 




FiCT. 86. — Gauze Wick in Drain. 





I r- 



M 



Fig. 87. — Mikulicz Drain. 



lections with gauze before they rupture and then thoroughly 
removing the pus and blood with dry gauze. The peritoneum, 
if given an opportunity, will take care of infection; the means 



128 GYNECOLOGY. 

which have been employed for the removal of infection have 
crippled the antagonistic processes of the peritoneum. 

201. Gauze Drain. — Drainage has been accomplished by 
a twist of gauze, or, where there was much oozing, by gauze 
pressure. The ■Mikulicz drain consisted of a piece of gauze 
with a string tied to its center, placed in the bottom of the 
pelvis, within which strips of gauze were packed. These strips 
were ordinarily marked, to designate the order in which they 
were introduced. The pain in removing was greatly decreased 
by covering it with rubber tissue except at its extremity. Drain- 
age, whether by tube or gauze, is of but short duration, and 
its influence is confined to a limited area. Lymph exudate 
soon walls it off as a foreign body from the general cavity. 
The gauze is very efficacious as a tampon. Its pressure arrests 
hemorrhage and promotes the formation of exudation, which 
closes oozing vessels and bars the avenues for the entrance of 
infection. 

202. Where Placed. — The drain, whether glass tube or 
gauze, was generally placed in the lower angle of the wound, 



i;*;«sS,-Ss::-j!'-s~- T^^ '^ ^-^^_ -S-i P> 




Fig. 88. — Gauze Drain Covered with Rubber Tissue. 

though it could be placed between sutures at whatever part 
of the wound was most favorable. 

203. Postural Drainage. — The uninjured peritoneum is a 
very active absorbing surface, and Clark utilized the knowl- 
edge of this fact to avoid the introduction of a drain by ele- 
vating the foot of the bed eighteen inches for from twenty- 
four to thirty-six hours, by w^hich the fluid gravitated away 
from the injured surfaces. The danger of infection was lessened 
by active irrigation with a large quantity of normal salt solution 
before the wound was closed. The activity of any pathogenic 
material remaining within the abdomen was diminished by 
dilution, through the retention of a considerable quantity of 
the solution when the wound was closed. 

This position also decreases the pain following an operation 
by the lessened quantity of blood sent into the vessels of the 
elevated pelvis. The pendulum has now swung backward, and 
we elevate the upper part of the body and favor the accumula- 
tion of fluid in the pelvis, from which it is removed by gauze 
wicks through the abdominal wound, or, better still, by an open- 



THERAPEUTICS. 



129 



ing into the vagina. The latter channel of egress should be 
emplo^^ed whenever possible, because it favors by posture the 
evacuation of the most dependent portion of the tract and the 
danger of sinus or hernia is lessened. 

204. Closure of the Wound. — Before the sutures are intro- 
duced, the omentum is generally drawn over the intestines. 
Formerly, when extensive adhesions or purulent discharges 
were present, the belly was left filled with a sterile normal salt 
solution. While we now urge the dry gauze sponge, it is yet 
difficult not to re- 
sort to the flushing 
with normal salt 
water when abscess 
cavities are rup- 
tured. The wound 
can be closed by 
through-and- 
through interrupted 
sutures or with 

buried sutures in separate layers. The interrupted sutures of 
silk, silkworm-gut, and silver wire or chromic catgut are intro- 
duced through the entire thickness of the abdominal wall, 
about three-fourths to one inch apart, including one-eighth 
of an inch of the peritoneal and one-fourth of the skin surface 
on each side. Each suture is secured with a pair of hemostats, 
and after all are introduced, the gauze pad placed over the 
intestines is removed, the cavity is inspected, and the sutures 
are tied. Care must be exercised that a knuckle of intestine 




Fij 



-Curved and Straight Needles. 




Fig. 90. — Needle Forceps. 



or a piece of omentum is not caught by the sutures. The most 
important consideration for the future of the patient is the 
union of the aponeurosis, for upon its accurate union depends 
the subsequent strength of the abdominal wall. 

While the single suture for all the structures will frequently 
afford a good wall, it too frequently results in a weakened ven- 
trum which gives way with increasing corpulency and becomes 
the site of hernia. After many trials with different methods of 
suturing I have accepted the following routine as affording 
9 



130 



GYNECOLOGY 



uniformly the best results. Begin external to the aponeurosis 
at the upper angle of the wound, carry a No. i chromic cat- 
gut suture through all the tissues below the aponeurosis at the 
right side of the wound, secure the end of the suture by hemostat, 
and ask the assistant to maintain at least three inches of it ex- 
ternally. With tissue forceps pick up and pass the suture 
through the peritoneum only upon the left side. The subse- 




Fig. 91. — I. Peritoneum Nearly 
Closed with Continuous Cat- 
gut. 2. Silkworm-gut Sutures 
through all Structures above 
Peritoneum. 3. Aponeurosis 
Being United with Continuous 
Suture of Catgut. 



Fig. 92. 



-Silkworm-gut Sutures 
Tied. 



quent turns of the suture are confined to the peritoneal margins 
'of the wound until the lower angle is reached, when the suture is 
brought through the aponeurosis at the left side of the incision. 
(Fig. 91.) With the Reverdin needle silkworm-gut sutures are 
now passed about one-half to three-fourths of an inch apart 
through all the structures above the peritoneum, and the ends 



THERAPEUTICS 131 

secured with pressure forceps. After drying the surface, begin 
at the lower angle of the wound with the remaining portion of 
the catgut suture, which closes the peritoneum and returns, 
closing the aponeurosis only until the upper angle is reached, 
when tie to the end at the right side of the wound. This method 
insures the accurate apposition of the aponeurosis and the res- 
toration of the rectus to its normal sheath. The silkworm-gut 
sutures are now tied with moderate pressure, insuring the obliter- 
ation of dead spaces, and places the muscle surface of the wound 
in a splint until the union can be secured. The ends of the silk- 
worm-gut sutures should be left long. (Fig. 92.) Left long, they 
promote drainage from the wound and facilitate their removal. 
The combined crescentic and vertical incision is closed by a con- 
tinuous suture for the vertical incision, which includes the peri- 
toneum and edges of the recti muscles. This suture of chromic 
catgut is only drawn sufficiently tight to hold the surfaces in 
apposition. A second continuous suture brings in apposition 
the edges of the aponeurosis, and a third will hold in contact the 
skin edges. This suture may be subcuticular, but a continuous 
suture through the skin edges, unless drawn tight, is equally effi- 
cient and more quickly introduced. The skin edges accurately 
apposed and the incision confined to the hair surface the scar is 
completely obscured in a few months. Great care must be 
exercised to control all bleeding vessels and, where there is a 
disposition to oozing, drainage should be installed to prevent the 
formation of a hematoma and its subsequent infection. 

205. Dressing. — After the wound is closed it is washed 
with alcohol and a sterile towel is pressed upon it, while the 
remaining surface of the abdomen is being cleansed and dried. 
The wotind surface should be dressed with several layers of plain 
sterile gauze. When the sutures are left long, the first pieces of 
gauze should surround them and the remaining portions be 
placed over the ends. The gauze should be covered with a pad 
of gauze and cotton or wood wool. The dressings are held in 
place with tapes attached to pieces of plaster, three on each 
side, and, finally, a sterilized bandage. The use of the tapes 
affords a ready access to the wound without annoyance to the 
patient. 

206. Postoperative Treatment. — The struggle for Hfe is too 
often, both by the laity and physicians, regarded as won when 
the operation has been completed, but in many cases this period 
but indicates the beginning of a grave battle. It is true that 
much may be done to lessen the trials of the after-period by care- 
ful study and preparation of the patient for operation, by the 
greatest expedition in the operation consistent with the most 



132 GYNECOLOGY. 

conscientious discharge of every detail of the procedure, the 
Hmitation of the amount of the anesthetic, and the early and care- 
ful regulation of the circulation. After the operation has been 
begun or half completed is no time for the surgeon to stop and 
hold a consultation as to what shall be the next step. He must 
have prepared himself by study, meditation, and experience for 
every possible complication and be ready to meet it when it 
arises. Postoperative or after-treatment comprises the con- 
sideration and exercise of those details which promote comfort, 
advance the convalescence, and enhance the restoration of the 
individual to normal health. Much of this work he must dele- 
gate to her attendants, but by his watchfulness and advice they 
must be governed. He should not himself, or allow^ others to, 
fall into the habit of following a routine treatment, but it should 
be directed to meet the necessities of the individual case. Under 
the old method of treatment where many cases had a glass 
drainage-tube inserted, it was necessary that the patient should 
be restrained to the dorsal position. Unless the patient is exceed- 
ingly nervous, very restless, apparently suffering intense pain, it 
is better to give no anodyne. When she is nerv^ous or com- 
plaining, an enema of tincture of valerian f5ij, with tinctura 
opii deodorati gtt. 20 to f o j, may be given. 

207. Comfort of Patient. — The patient is transferred from 
the operating to the private room, where she is placed in bed, 
covered warmly, protected from draft, and kept quiet ; the room 
should be darkened. If the operation has been protracted 
or the patient is depressed, hot-water bottles should be placed 
about her to maintain the body heat. These bottles should 
be tightly corked and a blanket should be placed between them 
and the skin. The patient, unable to understand or to make 
known her discomfort, may be badly burned if such precautions 
are not exercised. It should be recognized that the patient 
profoundly shocked has a lowered resistance, which will cause her 
to burn at a lower temperature than would occur in health. As 
she recovers, it becomes very irksome to remain in one position. 
An attentiv^e nurse can greatly add to her comfort by passing her 
hands under the patient so that the cool air reaches the heated 
back, by changing her from one side of the bed to the other, and 
by keeping the clothing under her smooth and dry. Unless there 
is some special contraindication, as the presence of a drainage- 
tube, she may be turned upon her side. Indeed, the early and 
frequent turning of the patient will prove beneficial. It pro- 
motes peristalsis, favors the early passage of flatus, and lessens the 
danger of unfortunate intestinal adhesions. The nurse should 
support the patient's back and limbs with pillows. One of the 
earliest symptoms of which the patient complains is intolerable 



THERAPEUTICS. 133 

thirst. It is better to limit the quantity of liquid for the first few 
hours to small quantities of hot water — a half ounce every hour, 
given with a horn spoon, as the china cup would burn the lips. 
Ice should not be given ; it increases the thirst and the patient 
will not be content without a piece constantly in her mouth. 
Both mouth and stomach soon become irritated. When the 
patient does well, she can have a cup of tea or coffee on the 
morning following the operation, small quantities of ice-water 
or soda-water, equal parts of effervescent vichy and orange- 
juice, a teaspoonful of beef -juice every three hours; and on 
the second day light food, and by the end of the week a generous 
diet. 

208. Vomiting should be an indication to discontinue every- 
thing by the mouth. Enemas of warm water, six to eight 
ounces, may be given to assuage thirst, and when the patient 
is in need of nourishment, nutrient enemas may be given every 
three or four hours. Nausea and vomiting occur very fre- 
quently after an operation and may continue several days. 
The ejected material may be the fluid which has been ingested, 
or bile, mucus, or the contents of the small intestine. The 
application of a mustard-plaster and an enema of 30 grains 
of chloral and i dram of potassium bromid in 2 ounces of warm 
water will often be sufficient to quiet the irritability. If the 
patient is constantly retching, it is better to give a large draft 
of water with i dram of bicarbonate of soda, a cup of weak 
tea, or some soda-water. 

Professor Hare has suggested 2 grains of acetanilid and 
^ of a grain of caffein citrate, to be repeated in two hours. I 
have found this formula of advantage in vomiting following 
etherization. Other remedies of more or less value are : cocain 
(4 per cent, solution), 3 drops every hour; tincture of mix 
vomica, 2 drops every hour; 2 drops of compound tincture 
of iodin and |- of a grain of carbolic acid every hour; or i 
drop of Fowler's solution every half -hour. The earlier the 
bowels can be evacuated, the sooner will the offensive material 
be removed; hence the most effective treatment will be the 
administration of a saline, or, when it cannot be retained, 
the use of calomel alone or in combination with bicarbonate of 
soda (gr. j-ij of the latter to from -^-J gr. of the former) every fif- 
teen minutes until gr. j-iss of calomel are taken, when magnesium 
sulphate one dram in syrup of ginger and cinnamon water is 
given every hour until the bowels are moved. In frequent 
vomiting a seidlitz powder is very efficient, for if vomited, it 
generally empties the stomach, and when retained, starts the 
current through the canal. The powder should not be given in 
the usual manner, but the sodium carbonate portion should be 



134 GYNECOLOGY. 

dissolved in water fSiij, tartaric acid dropped upon this dry 
and given immediately. The patient should be encouraged to 
retain this as long as possible. If vomited, the stomach is well 
cleansed and generally a portion of the drug passes the pylorus 
to exercise a good influence upon the intestine. A second pow- 
der may be given in the same manner a half -hour later if the first 
is ejected. 

If the intestine is distended and has not yielded to enemas or 
to the purgatives suggested, and the patient is constantly vomit- 
ing small quantities of dark fluid, nothing will give quicker or 
more lasting relief than irrigation of the stomach through a 
stomach-tube. When it is evident that the vomiting is an indi- 
cation of peritonitis, it is wiser to discontinue purgatives and 
be content with lavage. No food, not even water, should be 
given by the mouth, and peristalsis should be arrested by small 
doses of morphin hypodermically. Rectal feeding may be re- 
quired because of irritable stomach and the enfeebled condition 
of the patient, and especially in conjunction with the treatment 
suggested for peritonitis. 

Peptonized milk or broth may be given every three or four 
hours. When the patient is much depressed, a normal salt solu- 
tion and whisky or bovinin in combination may be given. When 
rectal feeding is practised, the bowel should be irrigated once 
or twice daily. 

209. Tympanites may be the result of a passive collection of 
gas in the intestines, or may indicate the development of peri- 
tonitis. The early passage of flatus is always an encouraging 
symptom. The sensation of distention may be promptly met 
by the use of an enema of — 

Magnesium sulph.,^ 

Glycerin, V aa 5 j. 

Water, J 

If relief is not secured, an enema of two tablespoonfuls of 
turpentine beaten up with the yolks of two eggs and strained 
into a quart of soapsuds should be administered. Keith recom- 
mends an enema consisting of six grains of quinin dissolved in 
four drams of whisky and two ounces of warm water, to be 
given every two hours until three doses have been administered. 
This prescription stimulates the nerve-centers and favors peris- 
talsis. The most effective agent to influence increased peristalsis 
is an enema consisting of an ounce of powdered alum dissolved 
in a quart of hot water. If peristaltic action is marked, but 
reversed, lavage should be employed, a hypodermic injection of 
morphin given, and followed, after a rest of three or four hours, 
by a repetition of the quinin. 



THERAPEUTICS. 135 

210. Shock. — Severe shock should be combated by the use 
of artificial heat, enemas of coffee and stimulants, suppositories 
of ice, elevation of the foot of the bed, bandaging the limbs, and 
the injection of normal salt solution into the buttocks, beneath 
the scapula, or directly into a vein. A hypodermic injection of 
strychnin (gr. 3-V— t) should be given according to the urgency of 
the condition, and followed by some aseptic preparation of ergot. 
Ergone in 20-minim doses is valuable, or it may alternate 
with (i : 1000) solution adrenalin chlorid, 20 minims every two 
hours. Atropin sulphate (gr. y^) twice daily will be serviceable 
in controlling the vessels. Where the loss of blood has been great, 
the renal secretion arrested, or shock profound, the intravenous 
injection of two to three pints of a one per cent, salt solution is 
the most effective agent Avhich can be employed. 

211. Anodynes. — The patient should be encouraged to bear 
the pain without an anodyne. When the pain is very severe, 
it may be allayed by the rectal use of chloral, 30 grains in two 
ounces of warm water. 

When the patient is very much distressed, it may become a 
choice between morphin and restlessness ; and a hypodermic in- 
jection of from ^ to J of a grain should be given. Morphin 
decreases peristalsis and favors tympanites, and consequently 
should, if possible, be avoided. Whenever it is evident that 
peritonitis has developed, that purgatives are ejected as fast as 
given, morphin with lavage should be considered our sheet anchor 
and be given for effect, giving an initial dose of gr. ^-J-, and fol- 
lowing with iV "to i every three hours. 

212. Internal hemorrhage, if the technic is perfect, should 
not occur. Its existence will be indicated by paleness of lips, 
feeble or absent pulse, sighing respiration, and clammy perspira- 
tion. The use of strychnin or the injection of salt solution 
favors the increase of hemorrhage. The only proper treatment 
is the prompt reopening of the wound, and the ligation of the 
bleeding vessel. 

213. Peritonitis. — Peritonitis is dependent upon infection and 
will occur early or late according to its virulence. The aim of the 
operator is, of course, to avoid the possibility of its occurrence, 
but the patient may in many instances have been infected prior 
to the performance of the operation, and all the skill of the opera- 
tor could not have removed the sources for further development. 
It is likely to occur in acute gonorrheal and septic infection of 
the tubes and pelvic structures, in large accumulations of blood, 
either prior to or subsequent to the operation, which have been 
infected from their juxtaposition to the intestines, soiling of 
the peritoneal cavity by the contents of dermoid, glandular, and 
papillary ovarian cysts. Peritonitis is characterized by in- 



136 GYNECOLOGY. 

creasing tenderness of the abdomen, decreased peristalsis, tym- 
panites, fre(^uent vomiting, especially when occurring on the 
second and third days; rapid, feeble, thready pulse, more or 
less elevation of temperature. The vomited material may be 
considerable, quantities of dark-greenish, bitter, and oftentimes 
foul-smelling fluid — apparently a much larger quantity vomited 
than the patient has taken. The tongue is dry, the patient com- 
plains of intense thirst, is constantly crying for water and ice. 
The administration of purgatives in these cases is generally in- 
effective, for the reason that the patient vomits or regurgitates 
everything as soon as taken. Enemas are of little value, as they 
only empty the lower bowel. The proper plan of treatment is 
to wash out the stomach with stomach-tube, give the patient 
a hypodermic injection of morphin, gr. -| or J, repeating this 
in doses of gr. yV to } every two or three hours, keeping the 
patient under its influence. As all efforts at increasing the per- 
istalsis are ineffective, we aim to place the intestines in a splint, 
remove the offensive material from the stomach and upper part 
of the intestine by lavage. Under this course we will frequently 
see patients that seem to be almost moribund become quiet, 
comfortable, resting easily; after two or three days there will 
be a profuse evacuation of the bow^els and the patient go on to 
recovery. The strength of the patient during this period should 
be maintained by hypodermic injections of ergone, strychnin, 
hypodermoclysis of normal salt solution in the breasts and the 
buttocks, and rectal feeding. If there is reason to suppose that 
an accumulation of fluid within the abdominal cavity has oc- 
curred, a vaginal incision should be made for its evacuation or 
the abdominal wound reopened and drained by gauze wicks. 
Having begun this treatment for peritonitis, the attendant should 
not be in too great haste to secure the evacuation of the bowels, 
as oftentimes the flame may be relighted by the too early ad- 
ministration of a purgative. 

214. Wound Infection. — It is the aim of the operator to se- 
cure healing of the wound by first intention, and every safeguard 
is thrown about the operative prpcedure in order to secure this 
object. Occasionally, however, in spite of all precautions the 
wound becomes infected from the material that is taken out of 
the abdominal cavity, or in closing the wound a vessel is punc- 
tured and hemorrhage of considerable quantity takes place into 
the tissues directly over the peritoneum. If the depth of the 
wound does not contain pathogenic germs, such an accumulation 
is likely to become infected from its close proximity to the intestine, 
and three to six or even ten days after the operation the patient 
may develop a temperature, complain of more or less tender- 
ness over the abdomen; the parts will be 'swollen. Where the 



THERAPEUTICS. 137 

abdominal walls are thick it will be difficult to recognize and 
determine the existence of any accumulation. It is better in 
these cases, however, where careful examination discloses the 
absence of any trouble within the pelvis or other portion of the 
body to account for the elevation of temperature, to make an 
exploratory puncture through the structures sufficiently deep 
that it may reach the space between the muscle wall and peri- 
toneum. If the operator fears to penetrate the peritoneum after 
making the incision through the aponeurosis, he can enlarge the 
opening by introducing a grooved director. The early evacua- 
tion of such an accumulation will prevent the suppuration and 
burrowing of the pus and will promote more rapid convales- 
cence. The infection in some cases may have been carried into 
the depths of the Avound in the removal of the sutures. 

215. Parotiditis.— Inflammation of the parotid gland is a 
complication of rather infrequent occurrence. It formerly, how- 
ever, occurred so frequently that it was considered that there 
was some intimate relation between this gland and the pelvic 
structures that caused metastasis of inflammation to it. It is 
now recognized, however, that its inflammation and infection are 
due only to the fact that this gland is more susceptible to the 
influence of some forms of bacteria than other structures of the 
body. Then, too, it is recognized that in the majority of in- 
stances the infection reaches the gland through the mouth and 
is due to local rather than general conditions. Where the patient 
is suffering from peritonitis or septic conditions, with dry tongue, 
decreased amount of saliva, the patient should be carefully 
watched and the mouth kept clean to prevent the entrance of 
infection to this gland. Where the gland shows signs of develop- 
ing inflammation, the most eft'ective treatment is to apply at 
once an ice-bag over the infected gland, keeping it constantly 
applied, thus limiting the amount of the inflammatory process, 
and where suppuration has occurred, the prompt evacuation of 
the pus by an incision. 

216. Ileus. — Ileus is an obstruction of the intestine that may 
take place one or two weeks after an operation is performed. It 
develops by nausea, vomiting, which goes on to the ejections of 
stercoraceous material, intense pain, profound depression, shock, 
rapid pulse, haggard, anxious expression, and, if unrelieved, is 
likely to terminate in the collapse and death of the patient. It 
is due to paralysis of a portion of the intestine from infection, 
from adhesions constricting and making difficult the passage of 
contents of the intestine through the tract, and twisting of the 
^ut, forming what is known as a a^oIvuIus or intussusception. 
If the patient is not relieved by lavage and hypodermic injection 
■of morphin, the wound should be reopened and the condition 



138 GYNECOLOGY. 

overcome. In the majority of cases the mere opening the abdo- 
men, freeing the adhesions, reestabhshing the caliber of the 
gut, wih be sufficient to accomphsh reHef . This procedure, how- 
ever, should be done early, as otherwise the patient will be so 
exhausted that it will be ineffective. 

217. Phlebitis. — Phlebitis generally affects the saphenous 
vein, sometimes extending into and involving the femoral and 
iliac. This infection may occur at a later date in a patient who 
otherwise has exhibited every indication of a normal convales- 
cence. A week or even two weeks after the operation has been 
performed the patient complains of intense pain in the calf of 
one leg, most frequently the left. The pain extends up along the 
course of the vein and most frequently is associated with tender- 
ness over the saphenous and the iliac veins. The patient should 
be kept perfectly quiet, the limbs should be raised, bandaged, 
first smearing over the course of the vein some ichthyol and bella- 
donna ointment, taking ichthyol and extract of belladonna aa 
3j, lanolin §j, wrapping well the limb with cotton, and apply- 
ing a bandage, making moderate pressure its entire length. The 
limb should then be elevated and kept more or less immobile by 
placing a sand-bag on either side of it. An ice-bag should be 
applied over the saphenous and iliac veins. Even after the acute 
symptoms have subsided the patient should be kept in the re- 
cumbent position and the limb perfectly quiet, as it is impossible 
to say in any individual case what may be the termination. A 
clot in the vein may become organized, obliterating the vein. 
It may break down, indicating suppuration and the formation 
of a localized abscess. Fragments of the clot may disintegrate, 
be carried into the circulation, and form emboli, blocking up the 
circulation to important viscera and giving rise to a fatal termi- 
nation. The nutrition of the patient should be maintained to 
the utmost degree. 

218. Precautions in the Use of the Hypodermic Syringe. — 
In the use of the hypodermic syringe there are four sources 
of infection: (i) The hands of the operator; (2) the instrument; 
(3) the fluids to be injected; and (4) the skin of the patient. 
The syringe is difficult to keep aseptic. The metal instrument 
may be boiled in a soda solution. If you have a glass instru- 
ment, the piston should be withdrawn and it and the barrel 
should be placed in a five per cent, solution of carbolic acid; 
the needles, if platinum, may be passed through an alcohol 
flame, but ordinary needles would be destroyed, and, therefore, 
they should be boiled. Solutions of atropin, morphin, cocain, 
strychnin, and ergotin favor the development of bacteria, and 
when kept for some time, will be found swarming with micro- 
organisms. Cocain may be kept in a (i : 10,000) bichlorid 



THERAPEUTICS. 139 

solution; the others named may be preserved by the addition 
of a few drops of carboHc acid to the ounce of solution. Prob- 
ably the safest method is to make up the solution of morphin, 
atropin, or strychnin from tablets, which can be dissolved by 
boiling without affecting the action of the drug. 

219. Catheterization. — No procedure, fraught with so much 
discomfort to the patient when carelessly employed, is so fre- 
quently performed with so little consideration as is the use of 
the catheter. We have to regard not only the distressing 
symptoms produced by infection of the urethra and bladder, 
but also the serious results of extension of the disease to the 
ureters and pelves of the kidneys. Fortunately, the female 
urethra is short, and permits the use of a glass catheter, which 
can be kept clean. The instrument should be scalded before 
and after being used, and should be kept in a five per cent, 
solution of carbolic acid during the intervals. It should be 
free from cutting edges. 

The labia should be separated to expose the urethral orifice, 
when the vestibule should be sponged with a solution of boric 
acid or sterile water. The catheter should be gently introduced, 
being held between the thumb and middle finger of one hand, 
while the index-finger is placed over its opening to prevent the 
premature discharge of urine. The instrument is carried up- 
ward and backward as the patient lies upon her back, and when 
it enters the bladder, as is evident by the absence of resistance 
and the appearance of urine in the instrument, its external end 
should be brought over the receptacle between the limbs of the 
patient. Should the quantity of urine be larger than the reser- 
voir will hold, the finger placed over the end of the catheter will 
permit it to be emptied and replaced. The bladder can be com- 
pletely emptied by making pressure over the lower abdomen 
with the unoccupied hand. With the discharge of the last 
urine the finger should be again placed over the end of the cathe- 
ter to prevent the urine flowing over the vulva or soiling the bed. 
When pressure has been made over the abdomen, the finger 
should be so placed before the removal of the pressure as to prevent 
the aspiration of air into the bladder. Should the urethra be- 
come painful or irritation of the bladder occur from frequent 
use of the catheter, the bladder should be irrigated with a hot 
boric-acid solution. After an abdominal operation the catheter 
need not be used for twelve hours unless the patient experiences 
much distress. 

220. Removal of Sutures. — The sutures in an ordinary case 
should be removed about the seventh to the tenth day. If 
the patient has had a complicated convalescence, the union 
will not be so firm, and it would be better not to remove them 



140 GYNECOLOGY. 

until the end of two weeks. If the sutures are pulling and 
causing pain, a part of them may be removed. The same care 
regarding cleanliness and avoidance of sources of infection should 
be practised as in the operation. Leaving the sutures long (see 
Fig. 92) will facilitate their removal and dispense with the neces- 
sity for forceps to lift up the knot. All the sutures should be 
cut before any are withdrawn, then the long ends may be gath- 
ered up and, bracing the wound with the fingers of the other hand, 
they may all be withdrawn at once, thus giving the minimum 
of discomfort. The wound should be dressed as in the begin- 
ning. 

221. Getting Up.— In uncomplicated cases the patient may 
be allowed to sit up at the end of two weeks. In complicated 
operations or in disturbed convalescence the patient should be 
kept recumbent for three weeks or more. When the patient sits 
up it should be for but fifteen or twenty minutes, and preferably 
in a chair, as the strain is less than if she is supported by a bed- 
rest. The time should be increased daily. 

222. Plastic Operations. — In plastic operations the same 
precautions as to cleanliness must be observed. Sponging can be 
replaced by the use of continuous irrigation. The parts may 
be dusted with acetanilid or iodoform and boric acid. The parts 
should be dressed with sterilized gauze held in place by a bandage. 

Vaginal irrigation should not 'be practised during the first 
forty-eight hours subsequent to an operation, for it interferes 
with the sealing of the wound by plasma. The patient should 
be confined to bed at least two weeks, and in perineal operations 
three weeks are preferable. In combined uterine, vaginal, and 
perineal operations the internal sutures, if nonabsorbable, should 
remain for three or four weeks. I prefer chromic catgut for all 
plastic work, for the reason that the patient is spared the dis- 
comfort of the removal of sutures, and the newly united tissues 
are not subjected to the strain. 



MEDICAL TREATMENT. 

223. General Treatment. — In every case of genital disease it is 
very important that the various organs of the body should be care- 
fully investigated as to the proper performance of their functions. 
It is a hopeless task to attempt to treat the disease of one organ 
of the body as if it were not an integral part of the whole, and 
capable of producing reflex effects upon organs near or remote, 
or of being itself the seat of reflex conditions. Engorgement of 
the hepatic system and the consequent hemorrhoidal congestion 
must be corrected. This is effected by purgatives, laxatives, and 



MEDICAL TREATMENT. 141 

alteratives. The patient should have calomel (gr. yV) ^^ podo- 
phyllin (gr. -2^) at night, followed the next morning by a Seid- 
litz powder, Rochelle or Epsom salts, phosphate of soda (5ij), 
or a wineglass of Hunyadi Janos or Friedrichshall water. If 
the liver is particularly sluggish, frequent applications of hot 
water over the hepatic region should be made. Ammonium 
chlorid or potassium iodid internally may be of service. 

Efficient action of the kidneys should be secured by the 
use of diuretics, or want of action should be compensated by 
increased action of the boAvels and skin. As anemia 'is a frequent 
accompaniment, the administration of the reconstructives, such 
as quinin, strychnin, arsenic, mercury, the bitters, and, in proper 
subjects, when the system has been prepared, the use of iron. 

Because of the profound effect this class of diseases exert 
upon the nervous system, the antispasmodics have found favor. 
In many cases the valerianate of zinc, asafetida, and the bromid 
salts will prove very grateful. In very nervous and anemic 
patients the cold pack, followed by massage, will be exceedingly 
beneficial. The state of the stomach, the heart's action, and the 
character of the respiration should always receive consideration. 

224. Specific Remedies. — The remedies w^hich may be con- 
sidered as specifically uterine in their action are ergot, hama- 
melis, hydrastis canadensis, and viburnum prunifolium. 

Ergot is generally given in hemorrhage. It acts in two ways ;■ 
(i) By stimulating the nonstriated muscle-fiber of the blood- 
vessels, increasing the rapidity of the circulation; (2) its direct 
action upon the uterine muscle, by which compression is made 
upon the vessels and a mass within the uterus is gradually 
extruded. 

A satisfactory prescription is — 

R. Ext. ergot f ^j 

Ext hamamelis.l aa f5ss M 

Tr. cinnamomi, / ^^ ^ 5 ss. m. 

SiG. — f 3j every two or three hours. 

This combination is generally more effective than the ergot 
used alone. If the contractions are painful, one or two drop's of 
the fiuidextract of cannabis indica will be of benefit. 

Hamamelis and hydrastis undoubtedly owe their action to 
the large amount of tannic acid they contain. Hydrastin or 
hydrastinin, in doses of from J to ^ of a grain, is more effectual 
in controlling hemorrhage than the fluidextracts. 

Viburnum prunifolium has been greatly vaunted as a remedy 
for the relief of dysmenorrhea or the arrest of threatened abor- 
tion, but I have never been able to obtain any perceptible value 
from its use. 

The extract of thyroid gland seems to exercise a specific 



142 GYNECOLOGY. 

influence upon the uterine mucous surface. In women who are 
very obese and have associated with the condition amenorrhea, 
or very scanty flow and steriHty, the administration of the 
thyroid extract, in addition to the reduction of flesh, increases 
the flow, and frequently appears to overcome the steriHty. The 
late Dr. E. H. Coover, of Harrisburg, found thyroid extract very 
effective in allaying the pain of advanced carcinoma of the 
uterus. He also thought that it had an influence in delaying 
the progress of the disease. This opinion seems in harmony 
with the observations of Beatson and others in carcinoma of 
the mammary gland. 

Thyroid extract is frequently of value in producing an im- 
provement in the conditions which occasion uterine hemorrhage, 
whether these be from interstitial endometritis, submucous 
fibroma, or carcinoma. Marked changes in the nutrition and 
the reduction in the size of myomata have been claimed for 
the use of this drug, but experience does not seem to justify 
them. 

Adrenalin, or extract of the suprarenal gland, through its 
action upon the involuntary muscular fiber, exerts a decided 
influence upon the uterine circulation. It is consequently a 
valuable addition to our armamentarium for the control of 
hemorrhage. 

Apiol and the manganese salts cause a hyperemia of the 
uterine mucous membrane, as indicated by increased normal 
menstrual flow and its return in amenorrhea. 

225. Rest and Exercise. — It is very difficult to flx definite 
rules to guide a patient as to the amount of either rest or exer- 
cise she should take. What one person may regard as a pastime, 
another will consider violent exercise. Women with inflam- 
matory or engorged uteri are beneflted by certain hours of rest 
each day. The recumbent position permits the blood-vessels 
to secure relief. Not infrequently relief is enhanced by ele- 
vating the foot of the bed or by resting the pelvis upon a firm 
pillow. In predisposition to hemorrhage from fibroid growths, 
the patient should be kept in bed for a few days prior to and 
during the menstrual period. Rest is obligatory in all acute 
inflammatory troubles. Some patients will, however, have 
to be stimulated to take exercise; they are disposed to go to 
bed on the slightest provocation, and remain so long that 
their muscles become flabby and the vessels grow feeble; the 
patient becomes bedridden, and every effort of exertion is at- 
tended with real or imaginary pain. Such patients may require 
resort to massage and electricity to enable them to resume 
their ordinary duties. 

Judicious use of the bicycle or encouragement to play golf 



LOCAL THERAPEUTICS. 143 

will be found most valuable auxiliaries in nervous patients 
who are dominated by imaginary aches and pains. The in- 
creased oxygenation and elimination without doubt free the 
patient from the cause of her distress. 



LOCAL THERAPEUTICS. 

226. Baths. — The sitz-bath of hot water in inflammatory 
and congestive conditions is capable of giving great comfort. 
This should be followed by rest, and it would be contraindicated 
where there was a tendency to hemorrhage or in a possible preg- 
nancy. In neurotic patients, a systematic course of hydro- 
therapy will frequently prove restorative when all other means 
have proved futile. 

227. Douche. — The value of the hot douche was made 
known by Emmet. It should be given with a gravity syringe 
while the patient is in a recumbent position; the more pro- 
longed, the larger the quantity, and the higher the temperature 
(115° to 120° F.), the more enduring will be the effect. The 
ordinary fountain syringe, a large vessel with a tube leading 
from its lower end, or an ordinary pitcher with a rubber tube 
carried to and held at its bottom by a weight, may be used. 
Instead of the ordinary rubber, wooden, or metal nozle, a glass 
end-piece is preferable, as it can be more readily cleansed. 
When preferred, the water may be medicated with astringents, 
such as alum, sulphate of zinc, acetate of lead, hydrastis, or 
hamamelis; or with antiseptics, as boric acid, carbolic acid 
(two to five per cent.), or permanganate of potash (one to two 
per cent.). The difficulty of saving the clothing from staining 
renders the use of the latter agent less frequent. Creolin (one 
to four per cent.) and acid sublimate (i : 5000 to i : 2000) are 
valuable. The antiseptic injections are of especial value in 
vaginal discharge, more particularly when of a specific character. 

The advent of menstruation is considered as contraindicating 
irrigation, but it may be resumed before it ceases, particularly 
when the odor is offensive or the parts are irritated, using plain 
water at a temperature of 100° F. If the vaginal discharge 
is particularly offensive, as in malignant disease, a douche 
of thymol solution, one or two per cent., is a most excellent 
deodorizer. 

Astringent douches are used in excessive vaginal secretion, 
but should not be used when the patient is wearing a pessary, 
as the salts are deposited upon the instrument, roughen its 
surface, and thus increase the irritation. 

Rectal douches may be employed to cleanse the bowel 



144 GYNECOLOGY. 

and for the relief of inflammation of the rectal mucous membrane 
or for their effect upon the neighboring pelvic organs. The 
close proximity to the uterus and broad ligaments, and the 
ability to retain the fluid longer in contact, make the use of 
the rectal enemas of hot water of especial value. Medicated 
enemas are used to unload fecal accumulations for the relief 
of tympanites, and to medicate local inflammations. 

Vesical douches are used for the relief of inflammatory dis- 
ease of the bladder and urethra. 

228. External Applications. — In acute inflammatory con- 
ditions the popular plan of treatment is to employ hot applica- 
tions, but we have in the ice-bag a far more efficient means 
of allaying pain and of limiting the area of inflammation. Its 
persistent application will in many cases secure resolution in 
what would otherwise prove a serious disorder. The ice-bag 
over the sacrum affords prompt relief of dysmenorrhea of the 
congestive form. 

229. Counterirritants are productive of benefit in the more 
chronic forms of disease. Painting the skin over the lower 



mr—- — H I I » 



Fig' 93' — Butt Uterine Scarifier. 

abdomen with tincture of iodin is more frequently resorted to. 
It may be repeated and continued so long as the skin will bear 
it. The irritation is increased by the addition of croton oil. 

R. 01. tiglii, f.^j 

Tr. iodi, f 3 ij 

^theris, f 3 V. M. 

SiG. — Apply with brush externally. 

It produces a crop of pustules, w^hich should be allowed to 
dry before the application is repeated. 

The most effective procedure is the application of a blister 
over the seat of pain or to the inflammatory exudate two or 
three times a month, but this should not be practised when 
the patients are much depressed or very anemic. 

230. Bloodletting. — The general abstraction of blood is 
now rarely practised. Doubtless there are many cases in 
which a good bleeding would cut short a severe iUness or abort 
an inflammatory attack. The local abstraction of blood by 
the use of a scarifier or by puncturing the cervix will often 
prove effective in relieving the pain of engorgement and in 
promoting absorption and resolution of inflammatory conditions. 



LOCAL THERAPEUTICS. 145 

231. Local Applications. — A few years ago the routine 
treatment was the introduction of soHd silver nitrate into the 
uterine cavity, the use of fuming nitric acid, and other power- 
ful caustics. Such treatment cured by destroying the glan- 
dular tissue of the part. Milder measures are now practised. 
It should be an accepted rule that no intra-uterine medication 
should be practised unless the uterine canal is freely open to 
permit of thorough drainage. 

Applications to the uterine cavity are made by wrapping 
a probe or applicator with absorbent cotton, which, after being 



Fig. 94. — Aluminiuin Uterine Applicator. 

saturated with the medicinal agent, is carried into the canal. 
A few drops of the medicinal agent may be introduced by the 
long pipet. In the use of either procedure it is desirable that 
the cervix shall be freely opened and the uterus in good posi- 
tion. If not, the medication will produce uterine contractions 
which will result in violent colic. Such attacks not infrequently 
are followed by severe inflammation of the adnexa and even 
of the peritoneum. To render intra-uterine treatment of value, 
the plug of thick mucus which generally fills up the diseased 



Fig. 95. — Long Glass Pipet. 

cervix must first be removed, in order to permit the contact 
of the medicinal agent with the aft'ected surfaces. 

232. Various Agents. — The agents generally applied locally 
may be classified as antiseptic, astringent, and caustic. The 
antiseptic applications are the combination of carbolic acid, 
creasote, iodin, and iodoform. Useful preparations are: 

K . Acid, carbolic. , ^ ss 

Tr. iodi, f gj. M. 

H . Creasoti, "] 

Glycerin., v . . . . ^ aa f 5 ss. 

Alcohol., ) M. 

R . Iodin (crystals), q.s. ad sat. 

Acid, carbolic. (95 per cent.), foj. M. 

E . 40 per cent, solution argvrol. 
10 



146 



GYNECOLOGY. 



An astringent effect can be secured by a combination of 
tannin, as: 

R . Acid, tannic, .^ j 

Tr. iodi, . . \ 7^^ fXi t\t 

Glycerin., | ^^^^^ ^^• 

The most frequent applications are the tincture of iodin 
and Churchill's tincture. 

Iodoform may be used in the form of crayons, as an oint- 
ment, or as a powder, with the insufflator. The various as- 




■^^;;; 



Fig. 96. — Insufflator — Straight Stem. 

tringents may be applied in powder alone or in combination 
with boric acid, iodoform, or acetanilid. 

233. Astringents. — The most available astringents are alum, 
borax, sulphate of copper and sulphate of zinc, the tincture 
of the chlorid of iron, fiuidextract of hydrastis, and fluid- 
extract of hamamelis. The solid substances are best used in 
mild solution. Some of these agents when used without dilution 
are strongly caustic. 

234. Caustics. — Crayons of sulphate of zinc (fifty per cent.) 

are very effective for caustic pur- 
poses, and are used in aggravated 
forms of endometritis. Still more 
effective is the chlorid of zinc in 
crayons (thirty-three per cent.). 

Liquid caustics are nitric acid, 
acid nitrate of mercury, sulphuric 
acid, hydrochloric acid, chromic 
acid, solution of zinc chlorid, solu- 
tion of silver nitrate, tincture of 
iron chlorid, carbolic acid, and crea- 
sote. In my judgment the more active caustics are rarely re- 
quired, and very frequently their employment is followed by 
cicatricial changes more grave than the original condition. 

235. Tampons made of absorbent cotton, lamb's wool, or 
gauze afford an efficient method of treating the cervix. The 
best tampon is composed of a combination of gauze and cotton 
or lamb's wool. It should have a thread attached, by which it 
can be withdrawn. The tampon may consist of simple sterilized 




Fig. 97. — Tampon. 



LOCAL THERAPEUTICS. 147 

material, or may be medicated with antiseptics, astringents, 
styptics, anodynes, or alteratives. The principal purpose of the 
tampon is to sustain the uterus at a higher level, which relieves 
the patient from the dragging pains due to want of support of 
a heavy organ, and the change of position improves the circu- 
lation; the addition of an antiseptic permits it to be retained 
for a longer period without becoming foul. Sublimate, from 
its tendency to irritate the vagina and vulva, can not be satis- 
factorily used. Carbolic acid, boric acid, and iodoform are most 
satisfactory. The addition of glycerin is of value. By its affinity 
for the watery portions of the blood it produces a profuse dis- 
charge, which depletes the vessels and favors the absorption 
of exudates. Boroglycerid, glycerite of tannin, and a ten to 
twenty per cent, solution of ichthyol are popular applications 
upon the tampon, but the patient should be cautioned, in the 
use of the two latter, to wear a napkin in order to prevent hei 
clothing from becoming stained. 

Besides supporting the uterus, the tampon may be used 
to control hemorrhage or discharge; to complete the diagnosis, 
through the discharge which it induces; to assist in maintain- 
ing the uterus in a normal position; and to prepare the way 
for the use of a pessary. 

236. Massage. — General massage affords an effective means 
of promoting nutrition and of improving the condition of pa- 
tients suffering from chronic pelvic troubles. It increases 
the number and the activity of the red blood-corpuscles, carries 
oxygen to the remote tissues and organs, facilitates oxgenation 
and combustion, and favors absorption, but, best of all, it im- 
proves the nerve tonus. Many patients are incapacitated by 
illness, by aggravated pains, or by disinclination to take exer- 
cise. Judiciously regulated massage accomplishes the con- 
stitutional changes ordinarily effected by exercise, free from 
its possible deleterious influences. Slowly the individual is 
rehabilitated, and as she gradually and insensibly resumes 
her self-control, she is emancipated from, the preexisting un- 
fortunate nerve phenomena. 

237. Pelvic Massage. — The beneficial results of massage 
in local inflammations of joints and superficial portions of 
the body justified the hope that it might be practised with 
advantage in the conditions of acute and chronic exudations 
within the pelvis. It has been systematized into a recognized 
procedure, known as pelvic massage, largely through the study 
and experiments of Thure-Brandt, a Swedish masseur. 

It is practised by having the patient lie upon her back upon 
a couch or table, with her buttocks close to its edge; the limbs 
are flexed upon the body. One or two fingers of the left hand 



148 



GYNECOLOGY. 



are introduced into the vagina, with which the uterus is gently 
pushed forward against the anterior abdominal wall. The 
fingers of the right hand are placed upon the abdomen, and 
are moved in a circulatory or rotatory manner over the sur- 
face, or, rather, moving the surface with them in this manner. 
(Fig. 98.) The greatest gentleness must be exercised in the 
beginning, increasing the pressure as the patient becomes 




Position of the Fino:ers in Pelvic Massag^e. 



reassured or as the pain is lessened. As we progress, the fin- 
gers may be made to dip down, to push off and separate ad- 
herent organs, and to follow lines of cleavage indicating in- 
flammatory adhesions. The seances vary in length from five 
to fifteen minutes, the shorter time being preferable in the 
earlier applications, and they should be repeated from three 
times weekly to once daily. The exercise of this procedure 



ELECTRICITY. 149 

will be found to produce a rapid alteration in inflammatory 
accumulations, setting free the uterus and its adjacent organs. 
The -procedure will be indicated in all subacute and chronic 
inflammations of the pelvic organs unassociated with pus-for- 
mation; in displacements, when fixed by inflammatory adhesions; 
in subinvolution and hypertrophy of the uterus from chronic 
interstitial inflammation; and in relaxation of the pelvic floor 
induced by increased weight of the pelvic organs. 

It is contraindicated in the presence of pus-formation, 
whether contained in the tubes or within the pelvic tissues. 

Massage is rendered difficult by thick abdominal walls, 
and in nervous, hysteric women. In the latter, however, much 
may be done by gentle procedure until the patient's confidence 
and cooperation are secured. 



ELECTRICITY. 

238. Forms. — The immense influence exerted by the use 
of electricity in the development of the arts and sciences nat- 
urally has led to its study and utilization in the treatment 
of disease. The various electric currents were early employed 
in an empiric way in gynecology. It remained for Apostoli, 
however, to formulate plans for their more accurate dosage 
and systematic use. The principal forms in which the electric 
current is generated and applied are Franklinic, galvanic, 
faradic, sinusoidal, and Ront genie. 

239. Franklinism. — Franklinism, or the static current, is 
the employment of electricity generated by friction. It is 
not generally used, but is an excellent nerve stimulant and 
counterirritant, from the use of which great benefit has been 
claimed in cases of hysteria and neurasthenia. It has afforded 
the greatest service to patients in whom the local pelvic lesions 
are slight or difficult to recognize while the element of pain 
is a marked factor. It has been employed with advantage 
in amenorrhea, dysmenorrhea, ovarian, lumbar, or lumboabdom- 
inal neuralgia, vaginismus, hyperesthesia, and various neu- 
rasthenic conditions. The seances may be continued from 
six to thirty minutes. The number of applications is indefinite. 

240. Galvanism. — The galvanic current has an extensive 
field for its application in the treatment of diseases of the pelvic 
organs. As a therapeutic agent its effects are recognized as 
polar, interpolar, and general (Martin). The polar effects are 
acid and alkaline at the respective poles. In very strong cur- 
rents the action becomes caustic. The positive pole is a power- 
ful sedative to the sensory nerves, and acts as a vasoconstrictor 



150 



GYNECOLOGY. 



of the blood-vessels in its vicinity. As a result of the accumu- 
lation of certain salts from the metal electrode employed, it 
proves destructive to germs. The negative pole with current 
of proper density causes liquefaction of the tissues, and if the 
current is very strong, it exerts an alkaline caustic action. 
It is a powerful irritant to the sensory nerves of the parts, and 
also acts as a vigorous vasodilator of the blood-vessels. Inter- 
polar action consists of electrolysis and cataphoresis, or transfers- 




Fig. 99. — Portable Galvanic Battery with Galvanometer. 



all fluids in bulk from the positive to the negative pole. Gal- 
vanism in its general effect, when forced through a portion 
of the body, acts as a tonic to the entire system. The beneficial 
influence of the agent in gynecology is most effectively dis- 
played in the treatment of chronic endometritis, pelvic inflam- 
matory exudates, and in some varieties of fibroid tumors. 

241. Apparatus for Application. — The investigations of 
Apostoli demonstrated that the application of high powers. 



ELECTRICITY. 



151 



of electricity resulted in the destruction of tissue in which 
acid materials were found about the positive pole, while alkalies 
collected at the negative. The former caused a dry, brownish 
eschar; the latter, a soft, watery, elastic slough, which did 
not contract. The resistance of the skin required for the use 
of high powers a large, inactive electrode externally. Apostoli 
devised and employed a moist clay pad. Other operators 
have used a bladder or other animal membrane filled with 
a salt solution, or a large metal disc covered with wet cotton 
or a towxl for the external electrode. The internal electrode 



^^^^^.m^ 



Fig. loo. — Intra-uterine Electrode with Movable Insulating Cover. 

may be vaginal or intra-uterine. The former may consist of 
a knob or a nest of knobs, from which a suitable one can be 
selected and attached to a gutta-percha-covered metal rod. 
The intra-uterine electrode may consist of a platinum wire 
or a steel rod insulated to within one or two inches of its end. 
The insulating sheath of gutta-percha or celluloid may be mov- 
able and thus permit a variable surface to be subjected to the 
application. 

A battery, either portable or stabile, will be required, cap- 
able of generating a current of from 200 to 400 milliamperes, 
and so arranged that the strength of the current can be gradually 




Fig-. 10 1. — Vaginal Electrodes of Different Sizes. 



increased. It should be provided with a galvanometer or a 
milliamperemeter to measure the current; a rheostat, by which 
the strength of the current can be governed; a commutator, 
to permit a change of poles without removal of the electrodes 
(as a reversal of the poles can not be made without shock, 
the precaution should be exercised greatly to reduce the in- 
tensity of the current before such a change is made). 

242. Method of Procedure. — Apostoli's employment of the 
electric current requires a careful examination and an accurate 
diagnosis. If a growth, careful measurement from various 
fixed points should be made in order to be able to determine 



152 GYNECOLOGY. 

the results of treatment. The hands, genitaHa, and electrodes 
must be thoroughly cleansed or disinfected. 

Before the external electrode is applied the skin should be 
carefully examined and all broken places covered with collodion 
or plaster; otherwise the electrode will be unendurable. 

The internal electrode should be introduced without the 
speculum. The patient should be apprised that there will 
be a slight burning, and that there may be a bloody discharge 
subsequently. Her clothing should be loosened, her corsets 
removed, and the bladder and lower bowel emptied. The 
application should not follow a full meal. 

While the electrodes are being introduced, the current should 
be closed, and gradually opened subsequently. The first ap- 
plication should be carefully made for the purpose of determin- 
ing the patient's sensibility. The pole used for the active 
or intra-uterine electrode must depend somewhat upon the 
existing conditions. The positive pole, possessing the most 
electrolytic action, and being an effective hemostat, should 
be employed for hemorrhage. The negative pole acts like an 
alkali, is the most painful, and is used to decrease the size of 
a growth or to enlarge a stenosed canal. The duration of the 
applications may vary from three to ten minutes. The num- 
ber of applications for an individual case is difficult to fix — 
generally from twenty to thirty. Their frequency is dependent 
upon the condition, varying from every eighth day to two or 
three times weekly. 

243. Indications. — The employment of galvanism is advocated 
in amenorrhea, dysmenorrhea, and menorrhagia; in chronic 
inflammation dissociated with suppuration; for the arrest of 
hemorrhage, relief of pain, and decrease of size in myomatous 
growths of the uterus, particularly in the submucous and inter- 
stitial varieties; and for chronic ovarian inflammation. This 
agent seems particularly valuable in women suffering from 
bleeding fibroids near the menopause,, in whom the conditions 
render a radical operation unjustifiable. 

244. Contraindications. — ^According to Apostoli, the galvanic 
current is contraindicated in the following conditions: (i) 
Hysteria; (2) intestinal catarrh; (3) pregnancy; (4) malignant 
degeneration of a tumor; (5) fibrocystic tumors; (6) suppurative 
inflammation of the adnexa. To these, Schaefler would add 
any acute or subacute inflammation of the pelvic viscera, a 
very hard or fully matured tumor, an excessively large growth, 
a submucous growth which is pedunculated, enfeebled heart 
action, and acute nephritis. 

245. Faradic. — The current of induction has a primary 
and a secondary current. One pole may be applied in the 



ELECTRICITY 



153 



vagina or the uterus; the other, over the abdomen. ApostoH 
advised a bipolar electrode in which the negative and positive 
poles were placed in the same electrode, with a band of non- 
conducting material between them. In this way the current 
of electricity was limited to a greater extent to the tissues de- 
sired to be affected. This method of procedure was less painful. 
The primary current is one of quantit}^; the secondary one of 
tension. The latter is dependent upon the length and fineness 
of the wire. The current of tension is effective in subduing 
pain, such as ovaralgia, abdominal pain in hysteric women, 
vaginismus, and pain from pelvic inflammation. It proves 




Fig. I02. — Faradic Battery. 



to be an emmenagog. It may be applied three times weekly, 
or even daily, each sitting lasting from ten to thirty minutes. 
The electrode is first introduced; the current is then opened 
slowly, and gradually closed before the electrode is removed. 
This is necessary in order to prevent severe pain. 

246. Sinusoidal. — Apostoli employed a current introduced 
by d'Arsonval, known as the sinusoidal. The patient is placed 
upon an insulated couch beneath which is a large coil of wire 
through which a current of 450 milliamperes is passed. The 
patient is enveloped in an electric atmosphere in which the 
effects will depend upon the number of alternations in a second, 
the degree of electromotive force, and the quantity of current. 



154 GYNECOLOGY. 

It acts more particularly upon the muscular structures with- 
out inducing pain or disagreeable sensation. Its employ- 
ment modifies nutrition by an increased absorption of oxygen 
and the greater ehmination of carbonic acid. The current 
exerts ^ a marked analgesic effect, which frequently induces 
the disappearance of painful symptoms. It is consequently 
of benefit in dysmenorrhea, but has displayed its beneficial 
effects to the greatest extent in the treatment of peri-uterine 
inflammations and pelvic exudates, in the resorption of which 
it is one of the most effective means at our disposal. 





Fig. 103. — Bipolar Uterine Electrode. 
+ . Positive pole. — . Negative pole. 

247. Rontgenic. — This term is applied to peculiar rays of 
light which are engendered by light under electric excitement, 
being transmitted through tubes of very high vacuum. The 
discoverer of this phenomenon. Professor Rontgen, of Wurz- 
burg, designated these rays as the :r-rays. The influence of 
the discovery of a procedure capable of transillumination of 
the structures of the body can hardly be estimated. The 
x-TSiys have proved both diagnostic and therapeutic aids. They 
can be generated through the employment of the static machine. 




Fig. 104. — Vaginal Electrode — Bipolar. 

the induction coil, batteries, and the electric-lighting main. 
The essential portions of the apparatus are the vacuum tube 
and fluorescent screen. The latter consists of a lightly con- 
structed tight box, somewhat similar in shape to the stereo- 
scope. The small end has an aperture which is made to fit 
tightly over the eyes and bridge of the nose. The inner sur- 
face of the broad end is covered with a uniform layer of fine 
crystals of a fluorescent material, generally barium platino- 
cyanid or calcium tungstate. Not only is the operator able 
to inspect the internal structures of the body, but he is also 



ELECTRICITY. 155 

able to record what he sees upon a sensitive photographic 
plate for the benefit of others. 

The employment of the procedure has afforded information 
of value in the diagnosis of obscure cases, notably in pregnancy 
and ectopic gestation. The beneficial infiuence of the rays 
in the treatment of superficial malignant and tubercular con- 
ditions suggests the hope that it may be equally eftective in 
arresting the ravages of these disorders when they involve 
the deeper structures. The rays are found to exert a more 
destructive action upon the less resisting malignant cells than 
upon the healthy tissues. If subsequent investigation shall 
demonstrate the correctness of this view^ which now seems 
probable, the operator who does not follow his radical opera- 
tion with the employment of the Rontgen rays to destroy in- 
fectious germ-cells w^hich have possibly lodged in the neighbor- 
ing lymphatic spaces and vessels will fail of doing full justice 
to the interests of his patient. In carcinoma of the cervix 
the depth from the surface of the tissues involved renders the 
application more difiicult, and requires special care to pro- 
tect the superficial structures from burns which would delay 
and arrest the necessary treatment. 

In deep-seated cancer my observation and the careful anal- 
ysis of that of others lead me to believe that not sufficient 
benefit is derived from the employment of the :^-rays to com- 
pensate for the discomfort of the applications and the occasional 
dermatitis arising from their employment. In superficial cancer, 
tuberculosis, obstinate eczema, acne, and pruritus the :r-rays 
have proved of advantage, but in malignant " disease of the 
deeper structures their employment should not precede surgical 
measures in operable cases. 

248. Finsen Light. — The Finsen light consists of the ultra- 
violet rays, which are invisible to our vision and are capable 
of refraction and concentration. They exist largely in sun- 
light, but may be artificially produced from the arc light. Glass 
is a non-conductor to these rays, therefore it is necessary to 
construct a plate or disc of quartz, or, still better, of trans- 
parent rock-salt. The Finsen light differs from the Rontgen 
rays in being very destructive to bacterial life, while the latter, 
if it has any effect, rather facilitates bacterial growth. The 
application of the Finsen light must, under present conditions, 
have a limited application in gynecology, because it causes 
an anemia of the tissues upon which it is purposed to exert its 
influence. 

249. Electrocautery and Light. — The employment of elec- 
tricity as a means for the production of heat for cautery pur- 
poses has won a well-recognized place through the work of 



156 GYNECOLOGY. 

Byrne with the galvanocautery, and later its ingenious applica- 
tion by Skene and Downes to electrothermic hemostasis. 

The power can be secured by batteries of large size, by 
storage cells, or, better, from the street main through a trans- 
former. Dr. Dow^nes has modified and improved the instru- 
ments devised by Skene. He applies a special form of angio- 
tribe to the broad ligaments, which, when raised to a dull red 
heat, divides and cooks the tissues, thus rendering ligatures 
unnecessary. 

The great advantage of this procedure is in hysterectomy 
for cancer of the uterus, as it enables the removal of a large 
amount of possibly infected tissue. The malignant cells which 
have been carried into the parametrium are supposedly less 
resistant to the effects of heat than healthy tissue. There- 
fore it seems reasonable to infer that some of these are de- 
stroyed by the electrothermic measures which w^ould other- 
wise survive to cause relapse if other methods of operating 
had been employed. 

The same class of batteries enumerated for cautery pur- 
poses may also be employed for electric lights. The electric 
light is especially useful in inspecting the urethra, bladder, 
ureters, and rectum. The electric light in a cystoscope can 
be introduced through the urethra and the entire cavity of 
the bladder exposed, the orifices of the ureters recognized, and 
any changes in the structure of the bladder are readily observed. 
The instrument may be employed to irrigate the bladder by 
closing its end; the bladder can be distended w4th air or gas, 
thus determining the capacity of the organ. Loss of structure, 
thickening, growths, and other changes in its walls are also 
perceived. It can also be employed for local medication and 
for catheterization of the ureters. The electric light can be 
employed to illuminate the rectum through long or short proc- 
toscopes, the vagina by an attachment to a speculum, and 
even to look into the uterus, but as the latter canal has to be 
previously dilated, the instances are rare when its illumination 
will be of practical service. 



EMBRYOLOGY AND ANATOMY OF THE GENITO -URINARY 
ORGANS OF THE WOMAN. 

250. Development of the Genito - urinary Organs. — Some 
knowledge of the origin and processes of development of the 
organs is necessary to a proper understanding of the condi- 
tions in which they have failed to attain the normal. The 
embryonic period may be divided into five periods or stages. 



EMBRYOLOGY. 



157 



rk 



• • 






The first period extends to the eighth week. Up to the fifth 
week from fecundation there is developed no sexual indication. 
The primordial kid- 
ney, the Wolffian 
body, the duct of Miil- 
ler, and the Wolffian 
duct, from which the 
genital organs are 
to be developed, are 
found one upon each 
side of the median line. 
A cloaca is situated at 
the site of the future 
vulva, into which the 
urachus and intestine 
open. From the ex- 
ternal surface of each 
Wolffian body a struc- 
ture known as the 
genital gland develops, 
which subsequently 
becomes either the tes- 
ticle or ovary. Simul- 
taneously, the cloaca 
is divided by a projec- 
tion — the genital emi- 
nence or tubercle — - 
which is marked by 
the genital furrow or 
groove. Their appear- 




i8 19 18 

Fig. 105. — Human Embryo at End of Thirty-five 

Days.— (Co5/^.) 
I. Tongue. 2. Aortic Bulb. 3. First permanent 
aortic arch. 4. Second aortic arch. 5. Third 
aortic arch, or ductus BotalH. 6. The two 
filaments to the right and left of this figure 
are the pulmonary arteries. 7. The trunk of 
the superior vena cava and the right azygos 
vein. 8. The common venous sinus of the 
heart. 9. Left auricle of the heart. 10. 
Right ventricle. 11. Left ventricle. 12. 
Lungs. 13. Stomach. 14. Left omphalo- 
mesenteric vein. 15. Wolffian body. 16. 
Right omphalomesenteric vein. 17. Intes- 
tine. 18, 18. Umbihcal arteries. 19. Um- 
bilical vein. 

tween the tube and 

the uterus. The cloaca, by the development of the perineum, 

is divided into two portions — the urogenital sinus and the anus. 



ance at the eighth 
week affords no clue as 
to the probable sex. 

The Second Period 
(Eighth to the Twelfth 
Week).— The Afiiller- 
ian ducts coalesce, and 
the septum disappears 
in their lower two- 
thirds, while the in- 
sertion of the round 
ligament indicates the 
point of division be- 



158 



GYNECOLOGY. 



The third period (twelfth to twentieth w^eek) witnesses the 
fusion of the uterine horns ; the appearance of the arbor vit« in 
the cavity of the uterus; the formation of the cervix; enlarge- 




Fisr. io6. — Coalescence of Miiller's Duct. 



ment of the perineum; and development of the vagina, which 
opens into the urogenital sinus and forms the vestibule of the 
vagina, in which the hymen appears. The genital tubercle, which 





Progress of Development of the Genitalia. 
Fig. 107. — All. Allantois. Fig. 108. — CI. Cloaca. Fig. 109. — Su. Urogenital 
R. Rectum. M. Miil- B. Bladder. R. sinus. R. Rectum, 

ler's duct. X. In- Rectum. V. Va- separated from the 

dentation of the skin gina. — {Schroder.) former by the peri- 

which forms the neum. B. Bladder, 

anus. — {Schroder.) V. Vagina, u. Ure- 

thra. — {Schroder.) 



has been large, is reduced to the proportions of the clitoris, and 
the edges of the genital fissure become the nymphse. 

The fourth period extends from the twentieth week to the 



ANATOMY. 159 

end of fetal life. During this period the fundus of the uterus 
increases in size ; folds form in the vagina, as well as in the cervix, 
and the labia majora become fuller and more rounded. 

The fifth period comprises the time from birth until puberty. 
The uterus increases in size and thickness; the uterine mucous 
membrane, which up to the sixth year is folded like that of the 
cervix, becomes smooth. The vagina is elongated, and the 
vulva is larger and more rounded. 

251. Division of the Genitalia. — The special generative 
organs of the woman are situated in the pelvis in close associa- 
tion with the bladder and urethra, the rectum, and the anus. 
The female genitalia are divided into two classes: the external 
and internal organs, the former of which, with the vagina, form 
the organs of copulation, and the latter the reproductive organs 
proper. 

252. The external genital organs are, enumerated from 
before backward, the mons veneris, the labia majora, the labia 
minora, the clitoris, the vestibule, perforated by the meatus 
urethras externus, the orifice of the vagina, surrounded in the 
virgin by the hymen, the fourchet, the fossa navicularis, and 
the perineum, situated between the vulva and the anus. The 
external genitalia are also called the vulva, pudendum, or 
cunnus; the cleft between the labia majora is known as the 
rima pudendum. 

253. The mons veneris is a cushion of fat situated over 
the pubes, covered with thick skin which is abundantly sup- 
plied with hair. The hair protects the vulva from the per- 
spiration of the body. When the nude woman is erect, the 
mons veneris is the only portion of the genitalia visible. 

254. The labia majora are skin folds which unite in front 
of the mons veneris. Posteriorly they thin off and terminate 
about one and one-half inches in front of the anus. Externally 
they are covered with short, crisp hair, which is continuous 
with that of the mons veneris. They are profusely supplied 
with sebaceous and sudoriferous glands. Their internal sur- 
faces lie in contact and present a smooth, moist surface which 
resembles mucous membrane. The apposition of the labia 
majora, slightly separated by the labia minora and clitoris, 
forms the cleft of the vulva, the rima pudendum. Each labium 
contains a sac-like structure called the dartoid. This is anal- 
ogous to a similar structure in the male scrotum. The round 
ligament, and in the fetus an open canal, called the canal of 
Nuck, terminates in this dartoid sac. Occasionally the latter 
remains open in the woman and permits the formation of a 
hydrocele. In fat subjects these folds contain a large quantity 
of adipose cellular tissue. 



160 



GYNECOLOGY. 



255. The labia minora are situated between the labia ma- 
jora, slightly projecting beyond their level, and are much more 
prominent anteriorly. Upon wide separation they are seen to 
be continuous with the fourchet, and form the posterior com- 
missure. Anteriorly they bifurcate and form two folds, an 
anterior, which passes in front of the clitoris and forms its 
prepuce or hood; the second passes behind the glans clitoris 




f 




Fie. no. 



-Virgin Vulva; Labia not Separated. — {From Deaver.) 



and forms the frenulum. The labia minora, also called the 
nymphse, have a smoother, but slightly roughened surface, with 
free convex, sometimes notched, borders. Frequently small 
openings or perforations will be seen. The size of the nymphse 
varies greatly according to the age and race. They project 
considerably beyond the vulva in the young child, but, owing^ 



ANATOMY. 



161 



to the increase in size of the labia majora as puberty approaches, 
they are rendered less apparent. In the Bush women the 
labia minora frequently become so long that they reach to 
the knees, and are then spoken of as the Hottentot apron. 
The skin is covered with a stratified pavement epithelium, 
similar to that of the true epidermis. They are plentifully 
supplied with sebaceous glands, especially at the base of the 
folds, where they form a crowded layer upon the inner surface. 
In the brunette the pigment deposit is frequently so great as 




Fig. III. — Virgin Vulva; Labia Separated, Showing the Hymen Unruptured. 

— (Frojn Deaver.) 

to make them noticeably dark. The skin folds contain a small 
amount of connective tissue. During the act of coition the 
labia minora draw the glans clitoris against the male organ. 

256.^ The clitoris, as in the male, is an erectile organ, having 
its origin from the posterior surface of the ischiopubic rami, 
arising on either side as a crus clitoridis or corpus cavernosum. 
These unite to form one body in front of the symphysis. The 
organ is secured to the symphysis by the action of the sus- 
pensory ligament, and its circulation is influenced by the ischio- 
cavernosus muscle, in which respect, therefore, it resembles 
11 



162 



GYNECOLOGY 



the penis. The corpora cavernosa are enveloped by a fibrous 
investment and separated by a median septum of cavernous 
tissue composed of fine trabeculae, in which the muscular ele- 
ments predominate. The free extremity of the clitoris is situated 
at the anterior part of the vulva, about one-half inch behind 
the anterior extremities of the labia majora. The organ is 
surmounted by a median tubercle known as the glans clitoridis. 
The glans is more or less covered by the prepuce, which is formed 
by the anterior folds of the labia minora or nymphag. The 
glans is imperforate and is generally but slightly developed. 





Fi^. 112.— Hvmen Crescens. 



Fig. 113. — Hymen Annularis. 



When it appears enlarged, the other parts of the vulva will 
generally be found small and ill developed. 

257. The vestibule is, by some anatomists, described as 
the entire space between the labia minora, which, prior to the 
rupture of the hymen, includes its external surface; but as 
this portion largely disappears after successful coition, and 
completely after parturition, it seems better to confine this term 
to the portion ordinarily called by that name, which is^ the 
space bounded on each side by the labia minora, and posteriorly 
by the anterior border of the vagina. This triangular space 
has the glans clitoridis at its apex. At its center, near the 
posterior border, is a rounded, pouting orifice — the meatus 



ANATOMY. 



163 



lorethrffi externus. The openings of the ducts of two clusters 
of large mucous follicles are also found in this situation. One 
of these groups lies immediately behind the clitoris, and when 
the ducts become occluded, a cyst is formed. The other group 
is near the sides of the meatus. Mucus is secreted very freely 
by these follicles under any persistent local irritation. In 
the virgin a grooved ridge is found which, according to Pozzi, 
represents the corpus spongiosum of the male and is known 
as the vestibular band. The orifice of the meatus urethras 
is situated behind the clitoris in the posterior part of the vesti- 
bule, and about one inch in front of the fourchet. It ordi- 




/I 


im 


»^- 




% s 












-^r^' 
%' 






'^-^■ 





Fig. 114. — Hvmen Serratus. 



Fig. iir — Hymen Infundibularis. 



narily presents a longitudinal or starred slit, the borders of which 
are shghtly notched and projecting. Occasionally its mucous- 
membrane bulges, forming a ring-like margin. Within the 
elevated margins of the meatus and slightly posterior to its 
center is found a minute opening, on each side, which usually 
is not easily detected in healthy subjects ; but following gonorrhea 
or leukorrhea they may be readily recognized. These openings 
are the orifices of Skene's ducts, w^hich are parallel to the ure- 
thra and about two centimeters in length. Thev should be 
recognized, as they are sometimes so large that a catheter 
may enter one of the canals instead of the orifice of the urethra. 



164 



GYNECOLOGY. 



258. The hymen is a thin membrane acting as a sort of 
diaphragm between the internal genital parts, on the one side, 
and the external parts and orifice of the urethra, on the other, 
which is revealed by separation of the labia minora. (Fig. iii.) 
Its external surface resembles the structure of the latter, while 
the internal presents not infrequently the rugae of the vagina. 
When the labia are not forcibly separated, the hymen appears 
as a vertical slit with its lateral edges in contact. With the 
labia held apart, however, the opening is usually crescent ic 
with its concave margin anterior. (Fig. 112.) Sometimes it is 
annular with a central opening. (Fig. 113.) The h3^men may 




-*^ > 




I 



Fig. 116. — Hymen Biseptus. 



Fig. 117. — Hymen Cribriformis. 



present a variety of forms and openings, such as the labial 
form, in which the lateral folds may be mistaken for the labia 
minora; the linguiformis, which presents a tongue-shaped 
projection posteriorly, and the falciform, which has a some- 
what long and wide orifice. The free edge of the hymen may 
be smooth, denticulated, or serrated. (Fig. 114.) Its structure 
may be thick and fleshy, and present irregular folds resembling 
fimbriae. The infundibular form (Fig. 115) presents a funnel- 
shaped appearance with the margins looking downward and 
backward. There may be two openings, the septus or biseptus 



ANATOMY, 



165 



(Fig. ii6), or a number of openings, as the cribriform (Fig. 117). 
The membrane is usually thin and easily torn, but occasionally 
it is so firm that it withstands the most strenuous efforts at 
coition, and, therefore, will require incision before the sexual 
act can be accomplished. The hymen usually ruptures during 
the first coition, and occasionally its tear is followed by pro- 
fuse and often dangerous bleeding. (Fig. 118.) The greater 
portion of the hymen is destroyed during the process of par- 
turition, the remainder shrinking together to form small masses 
at the vaginal outlet. These masses are known as the carun- 
culae myrtiformes. The number, form, and situation of these 
caruncles vary extremely. Generally 
there are three. One is situated at 
the posterior part, the others at the 
sides of the entrance to the vagina. 
Both surfaces of the hymen are cov- 
ered with pavement epithelium. The 
hymen guards the entrance to the 
vagina. 

259. The fourchet is a continua- 
tion backward of the labia minora in 
the form of a thin fold, and is rend- 
ered prominent by the separation of 
the vulva. Between this fold and 
the hymen is a boat-shaped depres- 
sion called the fossa navicularis. 
Between the fourchet and the anal 
opening is an intervening space cov- 
ered with integument, some four cen- 
timeters in length, which is called 
the perineum. 

260. The muscles of the perineum 
are exposed by the removal of the 
skin, the superficial fascia, and a 
layer of the deep fascia. The mus- 
cles thus mapped out are : The erec- 
tor clitoridis; the bulbocavernosus and the transversus perinei, 
paired muscles; and the sphincter ani and levator ani, which are 
single. The erector clitoridis arises from the anterior margin of 
the rami of the pubes and ischium and is inserted by tw^o ten- 
dinous expansions, one above the junction of the crura into the 
body of the clitoris, and the other below and in front. The h^dho- 
cavernosi muscles arise from the tendinous raphe and anterior 
aponeurosis of the perineum, and are separated by the vagina, 
around which they course, to be inserted by a thin slit into the crus 
of each side in front of the erector clitoridis. The outer fibers of the 




Fie 



118. 



-Laceration of the 
Hvmen. 



166 



GYNECOLOGY. 



muscle wind inward beneath the erector muscle to reach the upper 
part of the bulb near its isthmus. A portion of the median 
fibers are apparently derived from the sphincter and pass up- 
ward to the clitoris, over the pubes, and are lost in the super- 
ficial fascia. Other fibers form a delicate muscular arch in 
front of the body of the clitoris. The action of the muscle is 
to compress the bulb of the vagina and to some degree act as 
a sphincter of the vagina, though Savage assigns the latter 




Fig. 119. — Muscles of the Female Perineum. — (Deaver.) 



function to a portion of the levator am. The relation of a 
portion of the fibers to the sphincter ani produces a figure- 
of-8 action upon the two orifices, which it is important to re- 
member in operations upon the sphincter. The transversus 
perinei muscles arise one on each side from the tuberosity of 
the ischium, and are attached to the anterior aponeurosis of 
the perineal septum, the perineal body, and the skin of the 
perineum in front of the anus. The sphincter ani arises from 



ANATOMY. 167 

the tip of the coccyx and is attached in front to the tendinous 
raphe of the perineum, where it meets the fibers of the bulbo- 
cavernosi. Its fibers, closely attached to the skin, decussate 
in front of the anus, while some fibers appear to pass com- 
pletely around it. The muscle is pierced by radiating fibers 
from the longitudinal muscular coat of the rectum, and is in 
close relation with the levator ani and internal sphincter. This 
muscle forms the external sphincter and is voluntary in its 
action. The levator ani is the principal muscle of the pelvic 
floor. It arises from the back of the body and horizontal 
ramus of the pubes, the pelvic fascia (white line), and the spine 
of the ischium. From its origin the muscle sweeps downward 
and inward and is attached in the middle line from before 
backward as follow^s: To the vagina, to the rectum, to its fellow 
of the opposite side, and, finally, to the tip of the coccyx. The 
pubic fibers blend with the posterior half of the upper border 
of the sphincter vagincB. This muscle is more readily exposed 
from above. 

The vulvovaginal gland with the bulb of the vestibule are ex- 
posed in the dissection already described. The former is a 
racemose gland, of which there is one situated on either side 
of the vagina and posterior to its orifice. It is analogous to 
Cowper's gland in the male. It is also known as the vulvar 
gland of Bartholin, or, according to Huguier, the vulvovaginal 
gland. It is about the size of an almond, but varies in different 
individuals and even upon the two sides. Occasionally glan- 
dular nodules are seen, which seem to be detached from the 
gland and scattered in the surrounding muscle. Within, the 
gland is in close relation with the vagina, to which it is adherent 
by tense cellular tissue, while externally it lies beneath the 
bulbocavernosus muscle. Its excretory duct, about one centi- 
meter long, is directed from below upward and from without 
inward and opens in the angle between the hymen and the wall 
of the vulva. When the hymen has disappeared, its orifice 
is found in the corresponding angle between the carunculae 
myrtiformes and the wall of the vulva. It is usually difficult 
to detect, but sometimes presents an orifice which will admit 
a probe. This gland furnishes the secretion which is manifest 
under the influence of sexual excitement or during coition. 
The bulb of the vestibule is a venous mass which is situated 
along each side of the vagina and the vestibule. It is related 
within to the vagina, vestibule, and urethra, and is covered 
externally by the bulbocavernosus muscle. The bulbs unite 
beneath the clitoris by a venous connection, the pars inter- 
media. Kobelt says the injected bulb is nearly four centi- 



168 GYNECOLOGY. 

meters long, one centimeter wide, and from nine-tenths to one 
and one-tenth centimeters thick. Its external surface is convex, 
its internal surface concave. The bulb is a part of the erectile 
tissue of the female genital organs and is analogous to the cor- 
pus spongiosum in the male. 

261. The perineal fascia or the fascia of the pelvic floor 
consists of the following: 

1. The superficial fascia. 

2. A deep layer of the superficial fascia. 

3. The triangular ligament, composed of two layers. 

The superficial fascia is a continuation of the general fascia 
of the body. It consists of two layers — an outer, more or less 
loaded with fat, which is continuous with the same layer over 
the buttocks, thighs, and abdomen; an inner, more resisting 
membranous investment descends from the abdomen, narrowed 
to the width of the pubes, but spreading out so as to envelop 
the anterior perineal triangle at its base — the perineal septum. 
The abdominal portion of the fascia is firmly adherent to Pou- 
part's ligament; the perineal portion to the outer margin of 
the ischiopubic rami and the inferior margins of the septum, 
while the pubic portion is attached along a curved line of the 
bone, which indicates the origin of muscles of the anterior part 
of the thigh. 

A tubular prolongation extends backward from the margin 
of the external inguinal ring on each side of the vagina, nearly 
to the posterior vulvar commissure, and is known as the pu- 
dendal sac. With its fellow of the opposite side, when envel- 
oped with their cutaneous coverings, the two sacs form the 
labia majora. The pudendal sac contains more or less fatty 
tissue, and the terminal fibers of the round ligament of the uterus 
are also lost in it. The sac may be the seat of hydrocele from 
a patulous canal of Nuck, or a hernia may develop by a descent 
of a section of gut or omentum through this canal. The in- 
jection of air into the sac gives a similar appearance to that 
induced by hernia. The fascia passes around the transverse 
perineal muscles to form the anterior layer of the triangular 
ligament. This union forms the ischioperineal ligament — a 
very firm aponeurotic band attached to the outer ends of the 
rami of the ischii in front of their tuberosities. 

The deep fascia, or triangular ligament, has two layers — 
an anterior, or superficial, and a posterior, or deep. The super- 
ficial is attached to the rami of the pubes and ischium, and 
to the so-called transverse hgament of the pelvis, which lies 
immediately behind the subpubic ligament, from which it is 
separated by an opening for the dorsal vein of the clitoris. 



ANATOMY. 169 

Behind, it is united with the superficial, as well as with 
the deep, layer of the pelvic fascia. The deep layer is also 
attached to the rami of the pubes and ischium, and joins the 
obturator fascia covering the lower portion of the anterior 
surface of the levator ani muscle. In front it is continuous 
with the vesicorectal fascia; and behind, with the dense anal 
fascia which covers the under surface of the levator ani muscle. 

The junction of the three layers of fascia behind forms the 
ischioperineal ligament, which marks the boundary -line be- 
tween the urogenital and anal regions. 

The upper surface of the levator ani muscle is covered by a 
fascia called the pelvic, which is a continuation of the iliac. 
The pelvic fascia is attached to the iliac portion of the ilio- 
pectineal line and to an oblique line upon the posterior surface 
of the pubic bone, from above and within the obturator foramen, 
to just below the symphysis. It covers the inner surfaces of 
the ilium and ischium about halfway down the pelvic wall, until 
it reaches the so-called tendinous arch, which extends from the 
spine of the ischium to the pubic bone and below the obturator 
canal. This portion covers the obturator muscle, and is known 
as the obturator fascia. A thinner prolongation extends back- 
ward, and is known as the pyriform fascia. 

The pelvic fascia splits into two layers at the tendinous 
arch — an upper, called the vesicorectal fascia, which extends 
over the levator ani muscle, and a lower layer, which follows 
the obturator internus muscle to the inner edge of the ischio- 
pubic branches, and retains the name of • obturator fascia. 
Below the insertion of the levator ani muscle is given off an 
investment, which is called the anal fascia. In conjunction 
with the portion of obturator fascia below the tendinous arch 
it serves as a lining for the ischiorectal fossa. 

The vesicorectal fascia, from its insertion upon the pelvic 
wall, passes inward and downward and covers the upper sur- 
face of the levator ani to the base of the bladder, the vagina, 
and the rectum. In front, near the middle line, a thicker part 
of this fascia forms the anterior true ligaments of the bladder, 
or pubovesical ligaments. 

A ligament of the rectum arises from the ischial spine and 
is attached to the side of the rectum. It presents a double 
layer of fascia with intervening loose connective tissue, and 
permits a sliding movement of one part over another. 

A study of the relations of the pelvic structures to the la3^ers 
of the fascia results in the following, according to Hart and 
Barbour : 



170 GYNECOLOGY. 

r Superficial hemorrhoidal vessels and 
Between the skin and superficial fascia : ^ nerves. 

( Superficial perineal artery and nerve. 
Trans versus perinei. 
Bulbocavemosus. 
Erector clitoridis. 

Between the deep layer of the super- i Transverse perineal blood-vessels and 
ficial fascia and the anterior layer / nerves, 
of the triangular ligament: ) Venous plexuses. 

Bulbs of the vagina. 
Pudendal sacs. 

Dorsal artery and vein of clitoris. 
C Compressor urethrae. 
Between the layers of the triangular ) Vagina, in part, 
ligament: j Urethra, in part. 

V- Pudic vessels and nerves. 

262. Pelvic Diaphragm. — The structures already described 
as the soft parts, consisting of the pelvic fascia and the muscular 
structures, constitute the pelvic diaphragm, of which the most 
important structure is the levator ani. (Fig. 120.) 

The origin and insertion of this muscle have been given. 
It is generally described as two muscles, the levator ani and 
the coccygeus, but as there is practically no separation, this* 
seems an unnecessary distinction. Savage divides it into 
three, the pubococcygeus, the obturator coccygeus, and the 
ischiococcygeus, but this division seems inappropriate when 
we recognize the fact that none of the muscular fibers arising 
from the pubes reach the coccyx. The anterior portion of 
the muscle is covered by the muscles and structures of the 
external genitalia. The posterior portion is enveloped with 
the fascia and covered with the following additional layers: 
the skin; the adipose tissue filling up the ischiorectal fossa, 
and known as the ischiorectal fat. The boundaries of this 
irregular triangular space are the levator ani, covered by the 
anal fascia on the inner side, and the obturator internus muscle, 
covered by the obturator fascia on the outer side. The lower 
surface is bounded by the anterior edge of the gluteus maximus 
muscle and the greater sacrosciatic ligament behind, the trans- 
versus perinaei muscle in front, and the sphincter ani upon the 
inner side. The apex of the triangle is at the spine of the isch- 
ium. Behind, the two fossa communicate by the loose adipose 
tissue back of the rectum, and also by the pelvic fascia. In 
front, the fossa is limited by the line of junction' of the super- 
ficial and the deep fasciae. 

The posterior fibers of the levator ani pass behind the rectum 
and are continuous with those of the opposite side. Other 
fibers are attached to the tip and side of the coccyx. 

Action. — The pelvic diaphragm strengthens the pelvic floor, 
and, in association with its two enveloping layers of fascia, 



ANATOAIY. 



171 



forms a strong support for the uterus and bladder. Obser- 
vation of the movements of the floor, with the employment 
of Sims' speculum, reveals a rhythmic movement synchronous 
with respiration. The anterior pelvic segment goes down- 
ward and backward during inspiration and upward and for- 
ward with expiration. The muscle serves to raise up the rectum 
during defecation and draws the anus toward the symphysis. 




Fig. 1 20. — The Under Surface of the Levator Ani Muscle. — (Deaver.) 



The fibers between the rectum and vagina influence the size 
of the vaginal orifice. 

263. Perforations (Fig. 121). — The pelvic floor is perforated 
by three slit-like openings, two of which, the vagina and ure- 
thra, have axes parallel with the conjugate diameter of the 
brim. The rectum for a part of its course is similar, but turns 
backward at the lower part, where it is separated from the 
vagina by the perineal body. The axis of the anus is at right 
angles with the plane of the brim. Transverse section of the 
pelvis through the middle and lower third of the vagina shows 
it folded in the shape of a letter H, with a short lateral and 



172 



GYNECOLOGY. 



a long transverse bar. The urethra presents a transverse slit, 
and the rectum an anteroposterior fold. 

264. Internal Genitalia. — The internal genitalia are: The 
vagina, the uterus, the Fallopian tubes, the ovaries, and the 
parovarium. 

265. The vagina is a musculomembranous canal, lying be- 
tween the bladder and the rectum, and extending from the 
vulva to the uterus. It is fbced below by its attachments to 
the pelvic floor, and above surrounds the cervix, with which 
it is continuous. The direction of the vagina varies with the 
position and the condition of the adjoining organs — the bladder 




Fig. 121. — The Upper Surface of the Levator Ani Muscle. — (Deaver.) 



and the rectum. In the erect position it forms an angle of 
about 60 degrees with the horizon, and is parallel with the 
conjugate diameter of the brim of the pelvis. (Fig. 122.) Its 
walls are irregularly triangular, with the widest point at the 
upper part, where the uterus enters, which in the nullipara 
measures 3 or 4 cm. ; in multiparse, 6 or 7 cm. The anterior 
wall is the shorter, 5 cm. long, while the posterior is 7.5 cm. 
In the normal condition and with the bladder empty, the cervix 
enters the vagina at a right angle. This angle is rendered 
more obtuse by distention of the bladder or by an accumulation 
of feces within the rectum. The vagina is attached to the 
cervix about 1.5 cm. from the external os, and forms with 



ANATO:\IY. 



173 



the cervix a sulcus front and back. The former is known as 
the anterior, and the latter as the posterior, vaginal fornix. 
The anterior and posterior vaginal walls lie in contact, and, 




Fig. 122. — A Mesial Section; the Body Erect. — (Deaver.) 



Upon mesial section, present a slit with a slightly convex line 
directed anteriorly. Transverse section is represented by an 
H-shaped slit, the lateral arms of which are convex upon their 
inner aspect, with the horizontal limb bending shghtly anterior. 



174 



GYNECOLOGY. 



The vagina in multiparse is capable of wide distention, and 
is of quite variable shape. The anterior vaginal wall is united 
with the posterior surface of the bladder by loose connective 




tissue, which permits its dissection, though separation rarely 
occurs. The urethra is more intimately associated with this 
wall; however, it presents no difficulty in dissection. 



ANATOMY. 



175 



The mucous membrane of the anterior wall is thrown into 
numerous folds or projections, called the rugae, which are more 
marked toward the vulva and decrease in size as the upper 
end of the canal is approached. There are also temporary 
foldings, which disappear as the vagina is distended. The 
rugse consist of a series of transverse ridges, which extend 




Fig. 124. — Arteries and Nerves of the Female Perineum. — (Savage.) 
Internal pudic. 2, 3. Inferior hemorrhoidal. 4. Transverse perineal. 5. 
Superficial perineal or vulvar. 7. Profunda branch to the clitoris. 8. 
Artery of the bulb. 9. Dorsal artery to the clitoris. 10. Inferior 
hemorrhoidal nerve to sphincter and lower rectum. 11. Posterior super- 
ficial. 12. Posterior muscular. 13. Trunk of the nerve. 14. Anterior 
superficial branches to the vulva. 15. Anastomotic. 16. Pudendal branch 
of (17) the smaller sciatic. 18, 18. Continuation of pudic ending in nervous 
sheath for the clitoris. 19. Outer terminal branch of the ilio-inguinal 
nerve. A. Anus. M. Urinary meatus. C. Clitoris. L. Greater sacro- 
sciatic ligament. V. Vagina. O. Coccyx. A. Gluteus maximus. b. 
Superficial sphincter, c. Anterior edge of ischiococcygeus. d. Superficial 
transverse muscle. e. Bulbocavemosus muscle. /. Slip of anterior 
aponeurosis of perineal septum, g. Upper portion of erector clitoridis 
muscle, y. Adductor magnus, k. Gracilis muscle. T. Nerve-fibrils to 
integument. 



obliquely upward and outward from the longitudinal stem, 
known as the anterior column. 

The transverse projections are composed of secondary 
ridges, covered with papillae . The anterior column generally 
begins behind the meatus, and disappears in the upper third of 
the vagina; occasionally, its lower portion is divided into two 



176 



GYNECOLOGY. 



parts by a longitudinal groove, the opposite halves of which 
subsequently unite. The rugae are especially marked in young 
children and virgins, and largely disappear in the multipara. 
The posterior wall also presents a column with transverse rugae, 
but less marked than upon the anterior. 

The upper part of the vagina presents, when distended, 
a dome-like appearance, in which the posterior fornix is twice 

the depth of the anterior, owing to the 
higher attachment upon the cervix. 
The lateral fornices have no especial 
depth, and only connect the anterior 
and posterior. As the patient advances 
in years the vaginal walls atrophy and 
the rugae gradually disappear. 

The wall of the vagina consists of 
three layers : 
tissue layer ; 

muscular fiber ; and an inner, of mucous 
membrane. The exterior layer binds the 
uterus to the surrounding structures 
and supports the plexus of vessels and 
lymphatics. The muscle structure con- 
sists of longitudinal and circular fibers, 
intricately interlaced. A bundle of 
striated muscle-fibers is described by 
Luschka as surrounding the lower end 
of the vagina as well as the urethral 
orifice, which he calls the sphincter 



2 — 




an external connective- 
a middle, of unstriped 



The mucous membrane, which ex- 
tends from the free edge of the hymen 
to the cervix, over which it is reflected 
to the external os, varies in thickness 
from I to I J mm. It is of a rosy-red 
color, but may vary from a light pink 
to a dark-purple or slate color. The 
latter color is especially characteristic 
of pregnancy. The mucous membrane 
is closely attached to the subjacent 

muscular layer, and is thrown into the already mentioned rugas. 

The surface is covered with numerous papillae, which are greatly 

increased in size by pregnancy. 

The mucous surfaces are covered with an acid mucus, which 

is also markedly increased during pregnancy. 

The thickness of the vaginal wall is greater below, where it 

is about one centimeter, while at the upper part it is not over 



u 

Fig. 125. — Anterior Wall 
of Vagina, Showing 
Columnae Rugarum. — 
(Byford, after Savage.) 

I, 2. Anterior columns of 
the vagina, U. Ure- 
thral orifice. M. Cer- 
vix. 



ANATOMY. 177 

five millimeters. The difference in thickness is due to the varia- 
tion in the muscular wall. 

A microscopic section of the vaginal wall presents an ex- 
ternal layer of fibrous tissue, enveloping large veins, which belong 
to the A^aginal venous plexus. These are surrounded by bundles 
of smooth muscle-fibers suggestive of erectile structure. Accom- 
panying the veins are large lymphatics, some of which are^ dis- 






''&''-"• 



^ iVi. i/ 'C -^1 '■■■ '■■■ ^^_JS^>' ' ' V(L b 



1, )^V ^^ 



^ ' ~-^ :3: ^ _ C I -^1 ' ' , 



^M, 









Fig. 126. — Horizontal Section of the Vagina and Urethra of an Infant. 
a, a. Skene's glands. 6, 6, h, h. Urethral glands; the analog of Littre's glands 

in the male. 

tended to form sinuses. A middle or muscular layer is also 
present, in which the outer fibers seem divided transversely, the 
inner ones being longitudinal. 

The mucous membrane consists of a firm basement mem- 
brane in which are numerous elastic fibers. It is covered by 
several^ layers of stratified pavement epithelium. (Fig. 126."^) 
In addition to the large folds into which the mucosa is thrown, 

12 




178 . GYNECOLOGY. 

it forms secondary elevations, or papillae, in each of which 
is a capillary loop. These loops are single near the fornix, 
but present a more complicated network near the introitus. 

The rugce consist of large venous plexuses surrounded by 
bundles of muscle-fibers, as in cavernous tissue. 

The lymphatics are abundantly supplied to the mucosa. 
Lauenstein has described lymph-follicles similar to those in 
the intestine. 

The existence of mucous follicles or glands in the vagina 
is denied; the mucus is believed to be an exudation from the 
vaginal surface. 

The nerves ramify throughout the walls, communicate 
with one another and with the ganglia, and terminate in end- 
bulbs beneath the epithelium. 

266. The uterus, or womb, is a hollow, thick-walled, mus- 
cular organ, of a truncated shape, which occupies the upper 
part of the cavity of the pelvis and projects by a portion of 
its cervix into the vagina. It is situated between the bladder 
in front and the rectum behind. The fundus is usually just 
below the level of the plane of the brim of the pelvis, and about 
two centimeters in front of the sacrum. The position of the 
uterus is dependent upon the condition of the surrounding 
organs. When the bladder is empty and the rectum undis- 
tended, the uterus is slightly anteflexed, and occupies a posi- 
tion at a right angle to the axis of the vagina. The fundus 
is directed forward and upward, and the cervix downward 
and backward, toward the rectum. A distended bladder 
raises the fundus and decreases the uterovaginal angle. A 
similar change of position is induced by rectal accumulations 
which push the cervix forward. It necessarily is difficult 
then to determine between a physiologic and a pathologic 
position. We may call any position abnormal in which the 
organ becomes fixed and its range of mobility lessened. The 
uterus presents, from above, a pear-shaped appearance, slightly 
flattened from before backw^ard, and the posterior surface is 
the more convex. 

The length of the virgin uterus is from 5 to 7.5 cm.; its 
breadth at the orifices of the Fallopian tubes, 5 cm. ; and its 
walls are about i cm. thick. The weight of the nonimpreg- 
nated uterus is from about 300 grains to i-J ounces. The organ 
is divided into two portions — the body and the cervix. The 
body, pyriform in shape, about 4 cm. long, is surmounted, 
above a line drawn through the orifices of the Fallopian tubes, 
by a rounded portion — the fundus. The cervix, oCylindric 
in form, is about 3 cm. long and terminates below in the vaginal 
portion. Schroder divides the cervix into three parts — the 



ANATOMY. 179 

upper and lower, called the supravaginal and infravaginal por- 
tions, which are separated by an intermediate portion — a 
division which is of significance in the study of uterine dis- 
placements. 

The attachment of the vagina to the uterus is much higher 
behind. When the patient occupies the dorsal position, with 
the limbs well drawn up, the vagino-uterine junction is upon 
a 'plane vertical to the horizon. The infravaginal portion of 






Fig. 127. — Median Section of Uterus from Side to Side through the Fallopian 
Tubes. Mode of Junction of Vagina and Uterus. — (Savage.) 

a. Uterine cavity, b. Cervical canal, showing folding of its mucous membrane. 
d. Internal uterine (mucous) coat. c. Os externum uteri, e. Uterine 
aperture to Fallopian tube. f. Fallopian tube near uterus, g. Round 
ligament. V. Vagina. 

the cervix is especially interesting to the gynecologist, as it 
is the only part of the uterus which is visible upon inspection, 
and fully accessible to palpation. It varies extremely in size 
and shape, according to the age and sexual relations of the 
individual. In the virgin it presents a conoid projection, 
nearly one centimeter long, with an opening in its apex, known 
as the external os, or os tinc^. The os is a transverse sht, 
about two or three millimeters lon^:, and it divides the cervix 



ISO GYNECOLOGY. 

into an anterior and a posterior lip. The anterior lip is the 
longer. 

With the adA^ent of sexual activity the cervix changes. 
In the nulliparous married woman it becomes softer and larger, 
the conoid shape is less marked, and the os stands more widely 
open. In the multipara, even when lacerations have not oc- 
curred, the cervix is large and soft, and the os presents a trans- 
verse slit — more frequently an irregular opening. Inflam- 
matory lesions cause the cervix to become still larger, with 
e version of the mucous membrane, erosion of the surface, en- 
largement of the papilla, and an irregular opening. 

With the cessation of menstruation, and especially in women 
who have borne a large number of children, the vaginal cervix 
disappears and the os is flush with the fornix of the vagina. 

The junction of the triangular body and conoid cervix is 
called the isthmus. The anterior surface is flattened; the 
posterior, quite convex. The upper border of the uterus is 
rounded, and forms the fundus. The lateral uterine borders 
are obscured by the folds of the peritoneum, known as the broad 
ligaments. The upper part of each ligament is occupied by 
the Fallopian tube; below^ this, the round ligament; and still 
lower, the ovarian ligament. 

The arteries, veins, and lymphatics of the pelvis pass through 
the broad ligament. 

The uterine canal in the virgin (Fig. 128) is about five centi- 
meters long; slightly longer in the multipara. The cavity 
of the cervix is cylindric, wider in the center and narrower 
at each end, with the external os below and the internal os 
above. 

The cavity of the body is triangular from side to side, but 
the anterior and posterior surfaces lie in contact. At the apex 
of each angle of the triangle is found an opening, on each side 
the orifices of the Fallopian tubes, and below the internal os. 

The uterine wall has a thickness of a little more than one 
centimeter. The uterus has three layers — an external (serous) , 
a median (muscular), and an internal (mucous membrane). 
The serous or peritoneal covering is not complete, and, there- 
fore, will be considered with the peritoneum. 

The muscle-fibers are best studied in the pregnant uterus, 
and may be divided into three layers. The external is most 
distinct, and consists of a fine, thin layer over the anterior 
and posterior surfaces, from which prolongations are sent off 
into the broad ligament. The posterior fibers form the ovarian 
ligament, and the anterior the round ligament. Some of the 
fibers also furnish the longitudinal muscular structure of the 
Fallopian tube. These fibers are wanting upon the sides^of 



ANATOMY. 



181 



the uterus. The middle layer is by far the thickest, and con- 
sists of interlacing fibers, transverse and longitudinal, which 
are continuous with those of the vagina. This la^^er com- 
prises the principal part of the wall, and contains the blood- 
vessels. The latter are embedded in a network of fibers, and 
may be recognized with the naked eye upon cross-section. 
Their intimate relation to the muscle and tissue is recognized 
by their remaining open when divided transversely. 

The inner layer consists of 
circular fibers, which are most s^kW^'^ rv 

marked at the internal and "^mwW^f^J: 

external os, where thev form c'"^ '^ .■•/..-... -.^^ 




Fig. 128. — Virgin Uterus, Median 
Section. — {Byford, after Sappey.) 

I. Anterior surface. 2. Vesico-uter- 
inepouch. 3, 3, 4, 5, 6. Posterior 
surface. 7. Cavity of corpus. 
8. Cavity of cervix. 9. Os in- 
temvim. 10, 11. Vaginal por- 
tion of cervix. 12, 12. Vagina. 




Fig. 129. — Mucous Membrane of 
Uterine Body Showing Folli- 
cles. — {Mann.) 

d, d, d. Simple or double culdesac 
of these follicles, a, a, a. Thin 
cup-shaped orifice upon the mu- 
cous membrane. 



a sort of Sphincter, and at the cornu of the uterus, from which 
they are extended into the Fallopian tubes. 

The connective tissue of the uterus is thickly interspersed 
between the muscle-fibers, and especially along the course of 
the vessels. The mucous membrane of the uterine cavity 
rests directly upon the muscle layer without any intervening 
submucosa, and its glandular structure projects between the 
muscle-fibers. In the cervical cavity, where the mucosa is 
thrown into folds, a distinct areolar layer intervenes between 
it and the muscular wall. The uterine mucosa is one milli- 



182 



GYNECOLOGY. 



meter in thickness at the fundus, but becomes thicker near 
the center of the cavity. It is smooth and velvety, of a 
grayish-red color, and presents no folds, unless in the imme- 
diate vicinity of the tubal opening, and there but a slight 
folding. Under a glass can be seen numerous small depressions 
or openings — the orifices of the glands. The free surface of the 
mucosa is covered with a single layer of columnar epithelial cells, 







V5V:f'^:>^:./.^^<.,;;: 



-;?^/^? 






•■^. 






"rj^i'kW 4^V^y l^Vr'M^^ 




Fig. 130, — Section of Normal Endometrium. Note two glands to right some- 
what enlarged. 
a, a. Glands penetrating muscular substance. 

which are supplied with cilia. The mucosa is filled with glands 
of the tubular variety, which penetrate its entire thickness, 
and frequently their external extremities are embedded in the 
muscular layer. (See Fig. 129.) The direction of these tubules 
is more or less oblique. They often exist as sinuous or spiral 
single tubes, but more frequently divide into two or more 



ANATOMY. 



183 



branches near their lower ends. Upon longitudinal section 
they exhibit a basement membrane lined by a single layer 
of prismatic ciliated cells with single large nuclei situated near 
their bases. (See Fig. 130.) These glands largely increase 
with the approach of puberty, and become elongated during 
menstruation, and especially in pregnancy. The mucosa is 
supplied with large plexuses of capillaries and lymphatics. 
The latter, in the form of lymph-spaces, are directly connected 
with the lymph-sinuses and vessels of the deeper layer. The 
termination of the nerve-filaments in the mucosa has not been 
determined, but the action of the glands indicates their reception 
of nerve-filaments, as in similar 
structures of other parts of the 
body. 

The cervical mucosa, thicker 
than that of the body, is thrown 
into several folds, known as the 
arbor vitas, or plicae palmate, 
and is separated by a submucosa 
from the muscular wall. This 
arrangement of the mucosa ends 
sharply at the internal os, and 
is best observed in the virgin 
cervix. The mucosa differs from 
the lymphoid structure of the 
body in hvaing a firm, fibrous 
basement membrane, sur- 
mounted by cylindric epithelial 
cells. These cells, according to 
De Sinety, are ciliated only 
upon the summit of the ridges, 
while the epithelium covering 

the intervening surfaces is nonciliated. The glands are of the 
racemose variety, consisting of branching ducts. They are 
lined with nonciliated cuboid epithelium, resting upon a struc- 
tureless basement membrane. They open upon the free surface^ 
upon and between the folds, and secrete a clear, viscid, alkaline 
mucus. The ovula Nabothi are those glands of Naboth which 
have formed small cysts after occlusion of their ducts. 

The structure of the cervical wall differs from that of the 
body in the increase of fibrous tissue, which is intimately inter- 
woven with the muscle-fiber, and in the lessened supply of blood- 
vessels. 

The external os presents a sharp line of demarcation separating 
the one-layered cylinder epithelium of the cavity from the multiple- 
layered pavement epithelium of the vaginal portion. 




Fii 



i3f' 



Virgin Os and Cervix. — 
{Sappey.) 



184 GYNECOLOGY. 

267. The Fallopian tubes, or oviducts, are two tortuous canals 
which arise from each side of the fundus uteri. They vary- 
in size and length, occupy the upper margin of the broad liga- 
ment, and extend outward almost to the pelvic brim. The 
length of the tube is from 7.5 cm. to 12.5 cm., the right tube 
usually being the longer. 

They are first directed outward, then backward, and finally 
inward, giving the appearance of a shepherd's crook. The 
tube presents for our study: i, in the uterine cavity a narrow, 
funnel-like opening, the ostium uterini tubag; 2, the section 
of the canal found in the uterus, pars uterini; 3, the narrow 
portion proximal to the uterus, the isthmus tubae; 4, a wider, 
longer, more tortuous portion, the ampulla tubae, which ter- 
minates in, 5, a distinct trumpet-shaped end, the infundibular 
tubag, provided with numerous fimbriae, and, 6, a distinct open- 
ing from the ampulla, the ostium abdominale tubag. The line 
of differentiation between the pars uterini, isthmus, and am- 
pulla is not sharply defined. The isthmus is the narrowest 
portion and is about two centimeters long. The diameter 
of the isthmus is about two millimeters, and its lumen will 
scarcely admit a bristle. The ampulla is the more widened 
part; it extends outward and backv\'ard, has an external di- 
ameter of from six to eight millimeters, and its lumen a 
diameter of two or three millimeters. 

The fimbriated extremity — also called the pavillion, or in- 
fundibulum, from its funnel shape, and the morsus diaboli 
(devil's mouth) — is a trumpet-shaped opening, surrounded 
by primary and secondary fimbriae, which resemble the tentacles 
of the sea anemone. The primary fimbriae are the larger proc- 
esses, four or five in number, from which arise the eight or 
ten secondary processes. 

The longest fimbria (fimbria ovarica) anchors the tube to 
the ovary and has a furrowed groove, which facilitates the 
passage of the ovum to the tubal orifice. The broad ligament 
is continued to the lateral wall of the pelvis by a small fibrous 
band, known as the infundibulopelvic ligament. 

The tube, upon repeated section, will be found to have 
varying dimensions, and frequently its course is tortuous — 
almost convoluted. It has two openings — the uterine and 
the abdominal. The latter is more distensible than the remain- 
ing portion of the tube, is somewhat trumpet-shaped, and 
affords a communication with the peritoneal cavity. 

The tube consists of four coats or layers: the external, a 
serous, which is separated from the muscular by a subserous 
coat, the tunica adventitia; next a muscular; and lastly the 
internal — ^the mucous membrane. 



ANATOMY. 



185 



The external serous covering is incomplete, that portion 
of the tube toward the broad ligament being incomplete for 
the inner two -thirds of the tube. The remaining third is sur- 
rounded by the peritoneum, which covers the external surface 
of the fimbrise, while the internal is lined by the mucosa. The 
tunica adventitia envelops the muscular layer, allowing the 
peritoneal to slip over its abdominal end. The muscular coat 
consists of longitudinal and circular fibers. The former is 
continuous with the outer; the latter, however, is predominant 
and the continuation of the inner muscular layer of the uterus. 
The muscular structure is more largely developed at the prox- 
imal than at the distal end of the tube, and the circular fibers 









Fig. 132. — Section of Fallopian Tube through the Isthmus. 
a, a, Shows the firm and compact structure of the longitudinal folds in this 

portion of the tube. 



are particularly well marked at the isthmus, where they form 
what is called the sphincter tubas. The tubal mucosa is quite 
thick, thrown into longitudinal folds, very vascular, and of a 
bright red color. In the isthmus the mucosa presents simple 
folds, which become more complex in the ampulla. Hennig 
has counted from three to five primary folds, which have be- 
tween eight and ten smaller plicae between each pair of the 
former. The secondary folds are less marked near the abdom- 
inal extremity, where the longitudinal folding is apparent 
to the naked eye. 

The mucosa has a single layer of ciliated columnar epithe- 
lium upon two or three layers of supporting cells, which are 



186 



GYNECOLOGY. 



round or pyriform. The cells abruptly terminate at the ends 
of the fimbriae, where the margin between the columnar and 
pavement epithelium is distinctly marked. The tubal mucosa, 
like the uterine, has no distinct submucous layer, but unlike 
the latter, it is without glands, and is covered with a thin layer 
of grayish mucus of a distinctly alkaline reaction. 

268. Ovaries. — The ovaries, the germ-bearing organs of 
the woman, and the analogues of the male testicle, are a pair of 
small bodies, situated one upon the posterior surface of each 
broad ligament, below the tube and at each side of the uterus. 

The ovaries occupy a position at the level of the brim of 
the pelvis, or partly below and partly above its plane. 




Fig. 133- — Section of the Fallopian Tube through the Ampulla near the Isth- 
mus, Showing Extensive Folding of the Mucous Membrane. 



The axes of the ovaries lie obliquely to the pelvis, with a 
slight inclination forward. In the erect position they rest 
upon the posterior surface of the broad ligament. 

The Fallopian tube is situated in the broad ligament above 
the ovary and partly encircles it, while the round ligament is 
in front and occupies the anterior fold of the broad ligament. 
In front of the ovary, between it and the tube, is the parovarian 
structure, or the organ of Rosenmiiller. The inner or uterine 
extremity of the ovary is connected with the uterus by some 
muscle-fibers, about three centimeters long, known as the 
ovarian ligament; the outer or tubal extremity is connected, 



ANATOMY. 187 

above, with the end of the tube through the fimbrias ovarica, 
and below, with the infundibulopelvic Hgament. 

The ovary presents a flattened, ovoid appearance, with its 
broad end directed externally and the pointed end toward 
the uterus. The anterior, straight or flattened surface of the 
ovary is flxed by a short serous duplication, the mesovarium, 
to the posterior surface of the broad ligament. The posterior 
convex margin is free. Its size varies with the age of the in- 
dividual, the functional activity of the organ, and the occurrence 
of menstruation or pregnancy. The ovary attains its greatest 
size about six weeks after parturition (Hennig), and never 
reaches its former size in the subsequent involution. 

Following the menopause, it shrinks to one-half or one- 
third of its dimensions during active sexual life. Luschka gives 
its dimensions as: length, 4 cm.; width, 2.2 cm.; thickness, 
1.3 cm. It weighs from 60 to 135 grains. 

The color of the ovary is a pinkish-gray, becoming some- 
what darkened as menstruation approaches. Immediately 
after ovulation a dark swelling follows, due to the accumulation 
of blood. As absorption progresses the color changes and 
the mass becomes yellow, and later presents only a whitish 
cicatrix. Before puberty the ovary is smooth, but subse- 
quently it becomes irregular, from the cicatrices following 
repeated rupture of cysts, or nodular, from the presence of 
matured follicles that have failed to rupture. Following the 
menopause, the ovary becomes a pearly- white, irregular, almost 
cartilaginous mass, about one-half or one-third its former size. 

The ovary is situated upon the posterior surface of the 
broad ligament, with its pointed end connected with the uterus 
by the ovarian ligament. The ovary, by its pointed end, is 
directed toward the ligament, and its stroma extends inward 
upon the latter, while the external ovarian end is blunt and 
large. The posterior surface of the ovary projects through 
the peritoneum and is uncovered by it. The tmion of the 
columnar epithelium of the ovarian surface with the pavement 
epithelium is readily recognized as a white line, and is called 
the white line of Farre. 

Sections of the healthy ovary show two kinds of tissue, a. 
central or medullary and a cortical or peripheral portion. 
The latter covers the entire surface of the ovary bounded by 
the line of Farre, but projects to its greatest depth (two to 
three millimeters) at the central portion of the convex surface. 
The central structure has a pinkish-gray or rosy color, is of 
soft consistence, and has a moist, glistening appearance. It 
is of a white or grayish-white color, more or less firm in con- 
sistency, and contains numerous small vesicles. The smaller 



188 



GYNECOLOGY. 



vesicles are situated near the surface, while larger cysts are 
situated deeper. Some of these reach the size of a pea, and 
may project more or less beyond the free surface. The sac- 
wall is frequently so thin that the vesicles rupture under the 
slightest pressure. This layer also contains numerous depres- 
sions or scars, the result of repeated ovulation. 

The cortical layer of the ovar}-, or that part which projects 
through the peritoneum, is covered by a single layer of short, 




Fig. 134, — Section of Ovary, Showing Graafian Follicles. — (Wyder.) 



columnar epithelium, called by Waldeyer the germinal epithe- 
lium. This terminates abruptly at the white line, where the 
pavement epithelium of the peritoneum begins. Before puberty 
young ova are represented by large spheroid cells, with marked 
nuclei, which form in the columnar cells. Ingrowths of the 
germ epithelium into the underlying stroma are occasionally 
seen, which form the ovarial tubes of Pfliiger. 

Immediately beneath the epithelial layer, and quite insepa- 
rable from the underlying stroma, is the tunica albuginea — a 



ANATOMY. 189 

thin, dense layer of fibrous tissue, which contains a few smooth 
muscle-fibers. It is not completely developed until the third 
year, and undergoes changes Avith age and inflammation until 
it becomes thickened and of almost cartilaginous hardness, 
which renders its rupture exceedingly difficult. Such alterations 
from inflammatory changes are a cause of the formation of 
retention cysts, and of the development of that condition known 
as cystic disease of the ovaries. The structure of the ovary, 
as already noted, is divided into a cortical and a medullary 
portion, although they differ but little in structure except that 
the latter is softer and more vascular. In the cortical layer 
lie the Graafian follicles, embedded in connective tissue inter- 
spersed with some muscle-fibers. A large number of these 
follicles, variously estimated at from 36,000 to 400,000, are 
found in each ovary. Whether so large a number exists is 
difficult to determine, but it remains evident that nature has 
amply provided for the reproductive function. 

The ovarian stroma is the framework or bed in which the 
follicles rest and are nourished. Each Graafian follicle has a 
wall, which consists of a tunica fibrosa of thin fibrous tissue, 
within which is a more delicate membrane, called the tunica 
propria; the latter contains many granular cells and a fine 
network of capillary vessels. This tunica propria is lined with 
several layers of epithelial cells, called the membrana granulosa. 
These cells are separated from the tunica propria by a struc- 
tureless membrane. These epithelial cells form a thickened 
mass upon one side, which projects into the cavity — ^the discus 
proligerus. The cavity of the follicle is filled with a clear, 
serous fluid, called the liquor folliculi. It is formed by lique- 
faction of the cells of the membrana granulosa. 

The Graafian follicle, when mature, is one millimeter in 
diameter. Embedded in the discus proligerus is found the 
ovum, which has been called the typical cell; it measures from 
0.2 to 0.3 mm. It is a yellow, spheroid body, enveloped by 
a thin, delicate membrane, — the vitelline membrane, or zona 
pellucida, — doubtless formed from the innermost cells of the 
discus proligerus. Within this membrane is contained the 
vitellus, a network of granular, fibrillated protoplasm containing 
numerous fat-globules. In the outer portion of this network 
is a light spot, which consists of fine, fibrillated protoplasm, 
which contains in its meshes a granular material inclosed in a 
distinct membrane. This structure is known as the nucleus, 
or germinal vesicle. AVithin this is contained a small, highly 
refracting, granular body, known as the nucleolus, or germinal 
spot. 

The Graafian follicle is surrounded by a vascular network; 



190 



GYNECOLOGY. 



as it matures, the liquor foUiculi increases, the cyst becomes 
tense, approaches the surface, and the tunica albuginea be- 
comes thinned and finally ruptures, permitting the ovum to 
escape. The cavity of the follicle fills with blood, which coag- 
ulates and forms a clot. Later, this clot presents an external 

yellowish color, while its 
center is of a reddish- 
gray hue. The clot 
gradually becomes or- 
ganized, contracts (by 
which it is thrown into 
folds), and is gradually 
absorbed. The clot thus 
formed is known as the 
corpus luteum. The 
ovary of a normally 
menstruating woman will 
be found to contain a 
number of corpora lutea 
in various stages of retro- 
gression. The structure 
generally disappears by 
the end' of the twelfth 
week, excepting a small 
cicatrix, which remains. 
When pregnancy oc- 
curs, the corpora lutea do 
not continue to form, but 
the one corresponding to 
the last menstruation be- 
comes much larger and 
remains longer. It con- 
tinues to increase, and 
after the first month 
forms a large yellow 
clot, which gradually be- 
comes decolorized and 
more highly organized, 
resulting in a white, 
fibrinous clot surrounded 
by a yellow ring. The corpus luteum of pregnancy is known as 
the corpus luteum verum, while those which occur with ordi- 
nary ovulation are called corpora lutea spuria. 

Later in the pregnancy, the time of which is not exactly 
known, it becomes contracted, and at its termination forms a 
mass about 0.5 cm. in diameter. 




Fig. 135. — Large Corpus Luteum in Associa- 
tion with an Ovarian Dermoid. Re- 
moved from an Unmarried Woman Who 
Had Never Been Pregnant. — (Sutton.) • 

I. Twisted pedicle. 2. Corpus luteum. 3. 
Old clot. 4. Integumentary surface of 
dermoid. 



ANATOMY. 191 

When the corpus luteum has lost its color and most of its 
blood-vessels, and is mainly composed of a n;iass of fibrous tissue, 
it is called a corpus albicans. Frequently, from the retention of 
pigment, it is dark in color, and is known as a corpus nigricans. 
Clark has shown that the corpus luteum finally disappears by the 
process of hyahne degeneration. Extravasations of blood, or 
apoplexy of the ovary, we shall see later, are not infrequent, and 
occasionally may result in the complete destruction of the organ 
and the formation of a blood-sac — an ovarian hematoma. 

269. The Parovarium. — Between the outer end of the tube 
and the ovary is situated a triangular group of small tubules, 
known as the parovarium, or the organ of Rosenmiiller — a 
remnant of the Wolffian body. 

The structure corresponds to the epididymis in the male. 
The apex of the triangle is directed toward the ovary. This 
organ is of especial importance to the gynecologist, as it can 
be the seat of a number of growths. It consists of from six 
to thirty spiral tubules, which at their base open into a single 
transverse tube. This transverse tubule corresponds to the 
canal of Gartner in the lower animal. Cysts are frequently 
found associated with the tubules; the most common is the 
hydatid of Morgagni, or appendix vesiculosa, the pedicle of 
which arises in a point of the mesosalpinx, near the fimbria 
ovarica. The occurrence of this cyst is the rule rather than 
the exception, and it consists of a tough, connective-tissue 
wall with a well-developed vascular system, and is lined with 
pavement epithelium. It has a pedicle one-third centimeter 
long and contains clear fluid. The parovarium is entirely 
a rudimentary structure and has no function. 

270. Urinary Organs and Rectum. — Our knowledge of the 
relations of the pelvic organs will be incomplete without a 
study of the analogy of the urethra, bladder, and ureters, as 
well as of the rectum and anus. 

271. The urethra is a canal, from 2.5 cm. to 4 cm. long, 
which forms the outlet to the bladder. It lies embedded in 
the anterior vaginal wall, from which it can readily be separated. 
It is slightly curved upward, with its concavity forward. Upon 
cross-section the urethra presents a transverse slit near its 
vesical end and a stellate folding toward the external meatus. 
The diameter of the urethra is 0.6 cm., and it is quite distensible. 
When not distended, the urethral mucous membrane is more 
or less corrugated throughout its length, owing to the sphincter- 
like action of the surrounding muscle-fibers. The urethra 
is attached to the pubic arch by the pubovesical ligament, 
and penetrates the triangular ligament, between the layers 



192 GYNECOLOGY. 

of which it is surrounded by the fibers of the compressor ure- 
thras, or muscle of Guthrie. 

It is also, together with the vagina, influenced at its lower 
end by the bulbocavernosu^ muscle. Its external opening 
is known as the external meatus, and close inspection of its 
orifice will reveal a number of small openings about it — the 
orifices of the glandulae vestibulares minores. Within the 
meatus are two small openings — the orifices of the tubules, 
described by Skene. They correspond to the lacuna magna 
in the fossa navicularis of the penis. 

They are described by Skene as tubules which extend for 
a distance of nearly one centimeter parallel with the urethra. 
As a result of inflammation they can be so dilated that they 
will admit a No. i probe, and even the point of a catheter. 

The urethra is nearly parallel with the bladder, but when 
the woman is erect, it is nearly vertical. 

The urethral mucous membrane, like that of the vestibule, 
is of the pavement variety. The glands are lined at their 
mouths with pavement epithelium, which soon changes into 
the columnar variety. 

272. The bladder is situated in the anterior part of the 
pelvis, between the symphysis pubis in front and the vagina 
and uterus behind. Its shape is constantly changing with 
the accumulation and evacuation of the urine. When empty, 
the urethra forms the stem of a Y, the anterior limb of which 
is the longer. Between the urethra, the anterior surface of 
the bladder, and the symphysis is a triangular space filled with 
the retropubic fat. The bladder, when moderately distended, 
becomes rounded; and when full, oval. The female bladder 
holds less than that of the male, and dift'ers from it also in having 
the transverse diameter longer than the vertical. The bladder 
is divided into three portions: the body, the base, or fundus, 
and the neck. Skene defines the first as that portion which lies 
above a plane formed by the ureteric openings and the center 
of the symphysis pubis. The portion below is the fundus, or 
base, which includes the trigone, or space between the orifices 
of the ureters and internal meatus, and the bas fond, the space 
immediately behind the ureters. The thickened surface about 
the urethral orifice is the neck, which is the most dependent 
portion when the body is erect. 

The bladder-wall consists mainly of muscular structure. 
The wall, dependent upon the amount of distention, varies 
from 0.5 to I cm. The muscular structure consists of lon- 
gitudinal and circular fibers, the former mostly confined to 
the anterior and posterior surfaces. They may be traced 
from the vesical neck and pubes in front, where they are called 



ANATOMY. 



the musculi pubovesicales, to the summit, where some 
fibers accompany the urachus. 

The circular fibers are more marked near the vesical 
where they form the sphincter vesica. 



193 

of the 
orifice, 




Fig. 136. — Vesicovaginal Septum and Base of Female Bladder. Anatomic 
Relations of Ureters at Their Entrance into the Bladder. Contents of 
Alar Ligament. — (Savage.) 

I, I. Ureters. 2, 2. Uterine artery. 3, 3. Uterine veins. 4. Dotted line 
indicating the vaginal end of the uterine cervix. 5. Internal meatus 
urethrae. 6. Ligamentous process of fascia of pubococcygeus muscle and 
vesicopubic muscles. 7, 7. Pubococcygeus muscle. U. Uterine body. O. 
Ovary, utero-ovarian muscular ligament, and grooved Fallopio-ovarian 
fimbriae. T. Fallopian tube and fimbrias inverted. M. Parovarium. P. 
Pubic arch. V. Body of bladder. 

The muscular layer is partly covered externally by the 
peritoneum, which will be discussed later, and internally by 
the mucous membrane, with which it is loosely connected by 
13 



194 GYNECOLOGY. 

a layer of fibrous and elastic tissue. Because of this loose 
connection the mucous membrane is thrown into folds when 
the bladder is empty, except at the trigone, where it is more 
intimately connected with the submucous layer and is much 
thinner. 

The mucous membrane in life presents a rosy pink appear- 
ance, and is continuous with that lining the urethra and ureters. 
Its epithelium consists of three or more layers of epithelium 
resting upon a basement membrane. The superficial cells are 
squamous, but are smaller than the vaginal. The inferior 
layer is composed of columnar epithelium with long processes, 
while the middle one is made up of pyriform cells. The mem- 
brane is supplied with a rich plexus of fine capillaries and nerve- 
fibers; the latter are not marked in the trigone. 

The bladder is but poorly supplied with lymphatics, and 
they communicate with the glands near the internal iliac artery. 

273. The ureters are the urinary ducts through which the 
urine is carried to the bladder. Their course, previous to 
crossing the iliac arteries, is nearly parallel. The left ureter 
lies behind the sigmoid flexure of the colon. In their subse- 
quent course the ureters extend downward, backward, and 
outward, along the lateral walls of the pelvis. At the spine 
of the ischium they bend downward, forward, and inward to 
the bladder, passing behind the uterine arteries, and about 
I to 1.5 cm. on each side of the cervix. The distance between 
the ureters where they enter the bladder is 5 cm. They pass 
obliquely through the vesical wall and enter the bladder 2 
cm. below and external to the cervix, where their orifices are 
still 4 cm. apart, but united by a prolongation of the longitudinal 
fibers of the ureter, known as the interureteric ligament. This 
ligament forms a transverse ridge between the two orifices, 
and serves as the base of the vesical triangle. 

274. The Rectum. — The rectum is the lower extremity of 
the large intestine, and begins with the termination of the 
sigmoid flexure, at the level of the third sacral vertebra, to end 
with the anus. The rectum in its course from the third sacral 
vertebra is directed downward and forward behind the cervix 
uteri and vagina, parallel with the latter, until it turns directly 
backward at the anus. The relation of the rectum to the pelvic 
structures naturally divides it into two portions, the pelvic 
and the perineal portion. The pelvic portion begins opposite 
the third sacral vertebra and ends at the insertion of the levator 
ani into its wall. The perineal portion lies between the muscle 
and the anus. The space formed by the deviation of the rectum 
from the line of the vagina is occupied by the perineal body. 
The portion of the rectum involved in this deviation, which 
is about 2.5 cm. long, is known as the anus. 



ANATOMY. 195 

The entire length of the female rectum is twenty centi- 
meters. The canal is less curved than in the male, and its caliber 
is greater. The longitudinal muscular bands so characteristic 
of the colon are absent. 

The rectum, artificially distended, shows a very large sac, 
immediately above the anus, which decreases as the sigmoid 
flexure of the colon is approached. This very ^dilatable portion 
is called the ampulla, and when empty, the anterior surface 
lies in contact with the posterior, so that upon transverse section 
it presents a transverse slit. 

The anal orifice is quite dilatable. The anus forms an 
aperture which closes with its lateral surfaces in contact. The 
orifice is further obstructed by eight or ten longitudinal folds 
of the mucous membrane. These folds are called the ' ' columns 
of Morgagni," and the depressions between them, the "sinuses 
of Morgagni." These corrugations are produced by the con- 
traction of the sphincter, and disappear when the anus is dis- 
tended. Above the anus are three ring-like zones which are 
superimposed over each other. The first is the zone of the 
rectal columns and the intervening sinuses. The mucous 
membrane upon the surfaces of the columns is covered with 
pavement epithelium, while in the depressions cylindrical 
epithelium similar to that of the bowel above is found. Lie- 
berkuhn's crypts are seen only in the upper portion of this 
zone. Its boundary is often recognized as a distinct line, the 
linea ani rectalis (Hermann). The middle zone has a smooth, 
bright mucous membrane covered with pavement epithelium 
and small papilla. The lower zone is the cutaneous zone. 
This has the horny epithelium well supplied with pigment 
and also the connective-tissue sublayer characteristic of the 
skin. We find here papillae, hair, and sebaceous glands, ad- 
joining the large convoluted glands of the intestine. The 
submucous layer consists of a structure of quite dense con- 
nective tissue, in which are situated the blood-vessels, nerves, 
and lymphatics. Its laxity permits the mucous membrane to 
glide over it. The mucous membrane of the rectum above the 
anal canal has three or four large permanent transverse or ob- 
lique semilunar folds which often project quite a distance into 
the lumen of the bowel. These folds, according to Gant, are 
crescent-shaped, capable of some vertical motion, and extend 
about one-half to two-thirds the circumference of the rectum 
and project into its lumen from three-fourths of an inch to an 
inch and a half. They are situated obliquely to the long axes 
of the bowel. They are slightly cup-shaped with the con- 
cavities looking upward. With the bowel distended the free 
margins of these valves are prominent and readily seen through 



196 



GYNECOLOGY. 



the proctoscope. They are called Houston's valves.^ ' The 
number of them is variable; usually there are three. In ex- 
ceptional cases there may be five, six, or even seven. Their 
location is fairly constant. The upper valve is situated at 
the junction of the sigmoid and the rectum on the left rectal 
wall. The middle, which is the most prominent, occupies 
the right anterior wall opposite the base of the bladder and is 



RECTUM 



URETER (behind PERITONEUM) 
LOOP OF SMALL INTESTINE 



VERMIFORM APPENDIX, 
CECUM (displaced UPWARD) 



FUNDUS OF UTERUS 

FIMBRIATED EXTREMITY OF FALLOPIAN TUBE 



SIGMOID FLEXURE (DISPLACED UPWARD) 
LOOP OF SMALL INTESTINE 




TEEP EPIGASTRIC A. 

OBLrTERATED HYPOGASTRIC A. 

EXTERNAL ILIAC A. (BEHIND PERITONEUM) 

APPENDICULO-OVARIAN LIGAMENT 



ROUND LIGAMENT 



FALLOPIAN TUBES 
URACHUS 



Fig. 137. — Superior View of the Pelvic Cavity. — (JDeaver.) 



three inches or more above the anus. The lower valve is situated 
on the left side and a short distance below the middle valve. 
With the patient in the knee-chest posture and the rectum 
well inflated one can often see, by the aid of the proctoscope, 
all these valves at the same time. They generally form a sort 
of spiral stairway which gives a rotatory motion to the fecal 
mass as it progresses toward the anus. 



ANATOMY. 197 

The rectal wall is composed of three coats — the peritoneal, 
the muscular, and the mucous membrane. 

The arrangement of the serous coat will be considered with 
the peritoneum, but it should be remembered that a portion 
only of the rectum is enveloped by peritoneum. The mus- 
cular layer consists of longitudinal and circular fibers, but 
the former are more generally distributed, and not collected 
into bands, as in the colon. The circular fibers are deeply 
situated, and are more marked just above the anus, where they 
form a distinct ring, nearly half an inch in width, which is rec- 
ognized as the internal sphincter. The submucous layer 
consists of a layer of quite dense connective tissue in which 
are situated the blood-vessels, nerves, and lymphatics. Its 
laxity permits the mucous membrane to glide over it. The 
mucous membrane is continuous with that of the intestine, 
although much thicker and more movable than that of the 
colon, and its great vascularity causes it to have a bright pink 
or even red color. 

The mucous membrane is lined with columnar epithelium, 
and contains a large number of Lieberkuhn's follicles, but no 
villi. The mucous membrane at the anus abruptly changes 
from the columnar to the pavement epithelium of the skin, 
which forms the so-called white line. 

275. Pelvic Peritoneum. — That portion of the serous lining 
of the abdominal cavity which is situated within the pelvis, 
and envelops the pelvic organs, is known as the pelvic perito- 
neum. Upon examination of a mesial section it will be seen 
to leave the anterior abdominal wall about three centimeters 
above the symphysis and be reflected upon the fundus of the 
bladder. It covers the posterior surface of the bladder to 
the level of the internal os, and as much of the lateral surface 
as lies behind the obliterated hypogastric arteries. (Fig. 138.) 
From the bladder it crosses over to the uterus, the anterior stir- 
face, fundus, and entire posterior surface of which it invests. (Fig. 
139.) Laterally from the anterior surface it extends outward 
upon a plane perpendicular to the pelvic brim, and is attached 
to the lateral wall of the cavity, thus forming the anterior fold 
of the broad ligament. The peritoneal investment posteriorly 
extends over the uterus and upon the upper part of the vagina, 
nearly three centimeters below the uterovaginal junction. 
The lateral prolongation of this portion forms the posterior 
border of the broad ligament. The broad ligament contains 
the round ligament in its anterior fold; the Fallopian tube 
in its superior border, between the anterior and posterior folds; 
and its continuation from the termination of the tube is known 
as the infundibulopelvic ligament, the integrity of which is 



198 



GYNECOLOGY. 



of importance in maintaining the ovary, and even the uterus^ 
in position. Resting upon and projecting from the posterior 
fold, when the patient is erect, is the ovary, which is attached 
to the uterus by the ovarian Hgament. The anterior and 
posterior leaflets of the broad ligament are separated, in addition 
to the structures named, by considerable loose, vascular, con- 




Fig. 138. — Curved Dotted Line Shows Covering of the Anterior Uterine Wall 
by Peritoneum. — (Winter.) 

nective tissue, and afford entrance for the ovarian and uterine 
arteries and nerves, and egress for the veins and lymphatics, 
while its base is penetrated by the ureter on its way to reach 
the bladder. From the vagina the peritoneum is reflected 
backward, to be attached to the anterior surface of the rectum 




Fig. 139. — Posterior Surface of Uterus Showing Extent of Peritoneum; also 
Fallopian Tubes, Ovaries, and Ovarian Ligaments. — (Winter.) 



and to the tissues in front of the sacrum. Above the promon- 
tory of the sacrum it is continuous with the posterior abdom- 
inal peritoneum. 

The reflection of the peritoneum over the uterus and its 
extension as the broad ligaments upon each side divide the 



ANATOMY. 



199 



pelvis into two culdesacs — the anterior, or vesico-uterine, 
and the posterior, or uterorectal. The posterior culdesac is 
further divided by a prolongation of muscular structure from 
the sides of the uterus backward to the iliosacral synchondrosis, 
over which the peritoneum is reflected. This forms a deep, 
cup-shaped cavity directly behind the uterus, which is known 
as the pouch of Douglas. This pouch dips deeper on the left 
side, and sometimes extends to the upper border of the perineal 
body. When the bladder is empty and the nonpregnant uterus 
lies forward, the coils of small intestine usually occupy this 
pouch, except at its very lowest point, and intra-abdominal 




Fig. 140. — Vertical Transverse Section of the Pelvis, Showing Peritoneal Pouches. 

— {Luschka.) 
I, I. Levator ani muscle. 



pressure sometimes causes its dissection downward until a 
distinct hernia occurs behind the uterus. On either side, ex- 
ternal to the uterosacral ligaments, is a fossa, which is known 
as the para-uterine pouch. This has been called by Polk the 
retro-ovarian shelf. On the side wall of the para-uterine pouch 
the ureter may be seen beneath the peritoneum. This space 
is occupied by the small intestine. During pregnancy the para- 
uterine pouch is lifted up to the pelvic brim, while Douglas' 
pouch remains unaffected. From before backward, we may 
find the following pouches or depressions: first, the pubovesical; 



200 GYNECOLOGY. 

second, the vesico-abdominal, which is seen only during dis- 
tention of the bladder, and varies in depth according to the 
point at which the serous lining of the abdominal wall is re- 
flected. The vesico-uterine pouch is bounded in front by the 
bladder; posteriorly, by the uterus. This pouch varies less 
than the others, on account of the firm attachment of the perito- 
neum to the anterior surface of the uterus. In the empty 
bladder the bottom of this pouch is about three centimeters 
distant from the anterior culdesac of the vagina, and the pouch 
rises somewhat as the bladder falls. The study of the female 
peritoneum renders it evident that it differs from that of the 
male in not being a closed sac, as it communicates with the 
uterine mucous membrane through the orifice of the Fallopian 
tubes, and is again perforated by the ovaries, which project 
through it. The close relation of the peritoneum to the pelvic 
viscera renders any change in this structure perilous to the 
normal situation and relation of these organs. Inflammatory 
changes result in thickening and cicatrization, which produce 
temporary, if not permanent, displacements. The fixation 
of the uterus, compression of the ovaries, and obstruction of 
the orifices of the Fallopian tubes are necessary sequels of 
such alterations. The peritoneum, according to Luschka, 
serves as a sort of diaphragm, dividing the pelvic cavity into 
two portions : the one above may be called the intraperitoneal 
space, and that below, the subperitoneal. In the latter is 
situated the greater part of the pelvic connective tissue. 

276. Pelvic Connective Tissue. — The pelvic connective tissue 
is a loose cellular tissue, which acts as a padding for the support 
and safety of the pelvic organs. This structure is continuous 
with that which exists in other portions of the body. It appears 
in the pelvis in two varieties: first, as a loose tissue, distributed 
in an irregular manner around and between organs and between 
the layers of the broad ligaments, where it acts as a support to 
the blood-vessels and folds of the peritoneum; second, as firm, 
well-defined laminae or planes entering into the formation of the 
pelvic floor. These have already been described under the name 
of pelvic fascia. The connective tissue is continued behind the 
symphysis as the retropubic fat, and there lies in front of the 
bladder. Between the base of the bladder and the vagina it is 
rather firmly connected. On the posterior surface of the vagina 
there is a very loose layer connecting it with the rectum. A 
large mass is found on each side of the cervix uteri, forming under 
the broad ligaments what is known as the parametrium, which 
is united in front and behind by a much thinner layer. Over the 
body of the uterus the connective tissue is very slight and con- 
tains no fat. The rectum and vagina are embedded in consider- 



ANATOMY. 201 

able masses of this tissue. From the uterus and the parametrium. 
a thin layer extends between the leaflets of the broad ligament, 
and serves as a support for the vessels. The chief mass of this 
tissue is situated around the cervix, and extends downward 
aroimd the vagina to the insertion of the levatorvani muscle. 
The distribution and relation of the pelvic connective tissue have 
been studied in different wa^^s. The most valuable method is by 
the examination of frozen or spirit -hardened pelves, by which the 
position of the tissue, its amount, and its distribution are recog- 
nized. Injections of air, water, and plaster-of -Paris -have been 
made beneath the pelvic peritoneum in order to determine the 
lines of cleavage in the pelvic connective tissue and the directions 
in which pus would be likely to burrow. Konig made investiga- 
tions upon the bodies of women who had died shortly after labor 
from nonpuerperal disease. When an injection is made between 
the layers of the broad ligament, high up in front of the ovary, 
it first passes into the tissue at the highest part of the side wall 
of the true pelvis ; then into the iliac fossa, lifting up the peri- 
toneum; follow^s the course of the psoas, and passes but slightly 
into the hollow of the iliac bone; finally, it separates the peri- 
toneum from the anterior abdominal w^all some little distance 
above Poupart's ligament, and from the true pelvis below it. 
Second, when the injection is made beneath the base of the 
broad ligament and in front of the isthmus, the deep lateral 
tissue becomes filled first ; then the peritoneum is lifted from the 
anterior part of the cervix uteri. Separation extends to the tissue 
in the bladder, and ultimately along the round ligament and the 
inguinal ring, where it separates the peritoneum along the line 
of Poupart's ligament and enters the iliac fossa. Third, an in- 
jection at the posterior part of the base of the broad ligament 
fills the tissues around Douglas' pouch, and then follows the 
course as first described. 

277. The Vascular Supply. — The pelvic organs and perito- 
neum are supplied through the ovarian, uterine, vaginal, and 
internal pudic arteries. The ovarian arteries, analogues of the 
spermatic in the male, arise from the abdominal aorta just 
below the renal branches and pass downward over the psoas 
muscles beneath the ureters, enter the broad ligaments, and 
pass to the side of the uterus, near which each divides into two 
branches. The upper supplies the fundus uteri, and the lower 
anastomoses at the side of the uterus with the anastomotic branch 
of the uterine artery. In its course the ovarian artery gives off 
branches to the ampulla of the Fallopian tube and to the isthmus, 
and also numerous branches to the ovary. A smah branch 
is given off to the round ligament. The uterine artery springs 
from the anterior diA'ision of the internal iliac, passes downw^ard 



202 



GYNECOLOGY. 



and inward toward the cervix uteri, then upward between the 
layers of the broad ligament in a very tortuous course, and 
anastomoses with the lower branch of the ovarian. This portion 
is sometimes called the anastomotic branch, or the puerperal 
branch, as by its tortuous course it permits the vessel to be 
straightened out during the enlargement of the uterus in preg- 
nancy. The primary branches given off by the uterine artery 
are separated from the peritoneum only by a thin layer of muscle- 
fibers. These give off secondary branches, which penetrate the 
muscular wall in a direction at right angles to its mucous layer. 
They anastomose freely and end in capillary loops in the mucous 
membrane. The vaginal branches spring direct from the ante- 




Fig. 141. — Distribution of the Uterine and Ovarian Vessels. 



rior trunk of the internal iliac, but sometimes are given off from 
the uterine or the middle hemorrhoidal. A special branch of the 
uterine artery to the cervix joins with its fellow of the opposite 
side to form the circular artery of the cervix, and with the 
vaginal branches forms the azygos artery of the vagina. Ex- 
tensive anastomoses take place between the vessels of the oppo- 
site sides. The entrance of the vessels by the broad ligament 
enables us in extirpation of the uterus to control hemorrhage 
by ligation of the latter. The anterior division of the internal 
iliac also affords the blood-supply to the bladder and rectum. 
The perineal region is supplied by branches from the internal 



ANATOMY. 



203 




-25 
-20 



22 



Fig. 142. — Arteries of the Female Pelvic Organs. — -(Savage.) 

Vena cava inferior, receives right and left common iliac veins. 2, External 
iliac vein. 3. Abdominal aorta. 4. Inferior mesenteric artery. 5. 
Right common iliac artery. 6. External iliac artery. 7. Epigastric 
artery. 8. Obturator branch of epigastric artery. 9. Internal iHac 
artery, crossed in front by h, the ureter. 10. Uterine artery. 11. Obtu- 
rator artery; its course is along with and below m, the obturator nerve. 
L. Round ligament. 12. Inferior vesical artery. 13. Vaginal branch 
from it. 14. Uterocervical artery. 15. Artery of the Fallopian tube. 
18. Vaginal artery. 17, 17, 17. Spermatic arteries. 19. Pudic artery. 
20. Superior vesical artery. 21. Inferior hemorrhoidal artery, joined at 
22, another inferior vesical branch. 23. Posterior division of internal 
iliac artery, terminates in (24) iliolumbar lateral sacral, and (25) gluteal. 
26. Sciatic arteries. B. Bladder, u. Urachus. V. Vagina un distended, 
resting on R, the rectum. O. Ovary. T. Fallopian tube. 15. Fallo- 
pian branch. U. Uterus. L. Round ligament. S. Sacral articular sur- 
face of sacro-iliac symphysis. P. Pubic symphysis, articular surface, a. 
Pyriformis muscle, b. Gluteus maximus muscle, c. Obturatococcygeus 
muscle, p. Spine of the ischium. f. Psoas muscle. g. Linea alba. 
h, h. Ureters, i, j, k, 1. Trunks of sacral nerves resting on the pyriformis 
muscle, m. Obturator nerve, q. Peritoneum covering the transversalis 
fascia 



204 



GYNECOLOGY. 



pudic artery — a branch of the anterior trunk of the internal 
iliac. It passes out through the greater sciatic notch and enters 
through the lesser, passing around the spine of the ischium. In 
its course it lies upon the internal obturator muscle, and is 
inclosed with the pudic nerve in a canal formed for it by the 
obturator fascia. It gives off the following branches: The in- 
ferior hemorrhoidal; the transverse perineal; the superficial per- 
ineal or vulvar artery, which is much larger than the corre- 







Fig. 143. — Distribution of the Pudic Artery to the Structures of the Perineum. 

— (Deaver.) 

sponding branch in the male — the artery of the bulb ; the profundi 
branch to the crus clitoridis ; and the dorsal artery of the clitoris. 
The round ligament receives a small branch from the epigastric 
artery, which anastomoses with the branch from the ovarian. 
The venous distribution of the pelvis is very abundant, and occurs 
in the form of numerous plexuses, which freely communicate 
with one another. These veins are provided with valves. Con- 
sequently hemorrhage from an injured part will be very profuse 



ANATOMY. 



205 



when the whole pelvic vascular system is engorged, as, for 
instance, during pregnancy. Dissection discloses a vesical plexus 
which lies external to the muscular coat of the bladder. At the 
lower part of the rectum the hemorrhoidal plexus is found 
situated beneath the mucous membrane. The dis\;ribution of 
the veins of the labia is similar to that of the arteries. From 
the superficial portion they drain into the pudic, which com- 




Fig. 144. — Relation of the Urethral and Vaginal Venous Plexuses to the 
Veins of the Clitoris and Bulb, .The Right Side of the Pelvis Removed 
by a Section in Front, through the Pubic Body, about an Inch from the 
Symphysis, and. Behind, through Sacro-iliac Joint, — (Savage.) 

B. Bladder partially inflated, and b (vis), ureter cut just before it enters the 
bladder, V. Vagina distended, P. Section of pubis, R. Rectum, C. 
Clitoris, S. Sacrum, i. Bulb. 2. Its urethral venous process, 3, Lower 
efferent veins. 4. Dorsal vein of the clitoris, 5. Urethral venous plexus. 6. 
Commencement of vaginal venous plexus, 7, 8, 9, 10, Sciatic and gluteal 
veins corresponding to arteries, 11. Uterine veins assisting to form the 
uterovaginal venous plexus, 12. Obturator vein, 13, Internal iliac vein. 
a. Pyriformis muscle, b. Larger sciatic ligament, c. Pubo-, obturato-, 
and ischio-coccygeal muscles, d. Suspensory ligament of the clitoris. 
e. Bulbovaginal gland. /, /, /, Roots of sacral plexus of nerves. 



municates with the common iliac vein. The large veins from 
the labia minora open into the pars intermedia above. The 
blood returns from the glans and body of the clitoris through the 
dorsal vein of the clitoris, which communicates with the vesical 
plexus. The vaginal plexuses are situated, one in the submucous 
tissue and the other external to the muscular coat. They com- 
municate with the hemorrhoidal and vesical plexuses, receive the 



206 



GYNECOLOGY. 



blood from the veins of the bulb, and empty into the internal 
iliac vein. The uterine plexus is very complex, and empties into 
the ovarian veins. The right ovarian vein enters the inferior 




Fig. T45. — Veins and Erectile Venous Plexuses of the Female Pelvis. — (Savage.) 
B. Bladder. R, Rectum. L. Round ligament. U. Uterus. O. Ovary. V. 
Vagina. S. Sacro-iliac articulation. K. Kidney. T. Fallopian tube. 
P. Pubic symphysis, a. Pyriformis muscle, b. Gluteal muscles. c. 
Ischiococcygeus muscle, d. Internal obturator muscle, e, e. Psoas 
muscles, f. Linea alba, g, g. Ureters, h. Obturator nerve, i. In- 
ternal inguinal ring, site of canal of Nuck. i. Abdominal aorta. 2. 
Inferior mesenteric artery. 3, 3. Common iliac arteries, 4. External 
iliac artery. 5. Vena cava. 6. Renal veins. 7, 7. Common iliac veins. 
8. External iliac vein. 9. Internal iliac artery. 10. Gluteal. 11. Ilio- 
lumbar. 12. Sciatic. 13. Pudic. 14. Obturator. 15, 16. Epigastric 
veins. 17. Uterine vein. 18. Vaginovesical venous rete. 19. Spermatic 
veins. 20. Bulb of the ovary. 21. Vein to round ligament. 22. Fallo- 
pian veins. 



ANATOMY. 



207 



vena cava; and the left, the left renal vein. The right ovarian 
vein has a valve where it pierces the coat of the inferior vena 
cava, while the left has none. To this arrangement is attributed 
the greater frequency of pain and disease in the left ovary. The 
ovarian or pampiniform plexus lies between the folds of the 




Fig. 146. — Erectile Organs and Veins of the Female Perineum. — (Savage.) 
g. Crura clitoridis. i, 2. Bulb of the vagina. 3. Vestibular intercom- 
municating branches. 5. Superficial perineal and obturator veins. 6. 
Veins of communication with superficial epigastric veins. 8, 9, 10. Pudic 
vein and primary branches. M, Urethral orifice or meatus. V. Vaginal 
aperture. A. Anus. T. Tuberosity of ischium. O. Coccyx. G. Vulvo- 
vaginal gland. 



broad ligament and communicates with the uterine plexus. The 
ovarian plexus opens into the inferior vena cava. At the hilum 
of the ovary is situated the collection of veins known as the 
bulb of the ovary. The vesical, hemorrhoidal, and vaginal 
plexuses, with the pudic veins, empty into the internal iliac 
vein, which joins the inferior vena cava. From the hemorrhoidal 



208 



GYNECOLOGY. 



plexus there is a commtimcation with the portal system through 
the superior hemorrhoidal vein. 

278. The Lymphatic System. — This comprises: first, the 
lymphatic glands; second, the lymphatic vessels. The lymph- 







Fig. 147. — The Lumbo-iliac Lymphatics and Glands. Lymphatics of the 

Gravid Uterus and Appendages. — (Savage.) 
1,2. Superior lumbar glands. 3, Inferior lumbar glands. 4. Sacral lymphatic 

glands. 5. External and internal lymphatic glands. 6. Common iliac 

glands. 5, 7. Spermatic lymphatic plexus, a. Left renal vessels, b. 

Left renal vein. c. Left spermatic vein. d. Left spermatic vessels, 

covered by their lymphatic plexus, e. Aorta, f. Common iliac trunks. 

g. Ascending cava. h. External iliac artery and vein, m, n. Ureters. 

o. Right common iliac vein. p. Iliacus muscle, s. Psoas muscle. O. 

Ovary reversed, showing lymphatics between it and its bulb. 



atic glands are: (A) the inguinal glands, which lie parallel to 
and just below Poupart's ligament ; (B) the pelvic glands. (Fig. 
147.) These comprise: (a) a gland situated at the isthmus uteri ; 
(b) the hypogastric or iliac glands, which lie beneath the perito- 



ANATOMY. 209 

neum, in the space between the internal and external iliac vessels ; 
(c) the sacral glands, situated on the lateral aspect of the anterior 
surface of the sacrum and the mesorectum ; (J) a gland or small 
collection of glands at the obturator foramen, known as the 
obturator gland of Guerin. All these glands discharge into the 
lumbar glands, which lie in front of the lumbar vertebra, and 
finally into the thoracic duct. The lymphatics of the external 
genitals form an extensive network on the internal aspect of 
the labia majora, over the labia minora, around the vaginal and 
urethral orifices, the vestibule, and the clitoris, and all these 
discharge into the inguinal glands. As a consequence, syphilis 
or cancer affecting the vulva or lower fourth of the vagina causes 
involvement of these glands. In the upper three-fourths of the 
vagina and cervix uteri the lymphatics open into the hypogastric 
glands. This is true not only of the lymphatics of the upper 
three-fourths of the vagina and cervix, but also of the lymphatics 
of the bladder. The lymphatics of the uterus pass through the 
broad ligaments with those of the ovary and tube and enter 
the lumbar glands. Some of the uterine lymphatics pass along 
the round ligaments to the glands of the groin. Leopold, in 
investigating the lymphatics in the unimpregnated uterus, re- 
gards the mucous membrane of the organ as a lymphatic surface 
consisting of lymph-sinuses covered with endothelium. The 
lymph passes from these spaces into the vessels of the muscular 
coat, and flows into the larger vessels which enter the broad 
ligaments. The distribution of these vessels and their extensive 
character account for the rapidity with which septic matter 
is absorbed from the uterine cavity and explain the various 
routes by which bacteria can pass through lymphatic canals or 
penetrate the blood-vessels. 

The lymphatics of the rectum lie in the mucous and muscular 
layers and communicate with the glands of the mesorectum or 
the sacral glands. 

Nerves. — The nerves distributed to the pelvic organs are 
derived from the spinal and sympathetic. The branches from 
the spinal nerves consist of the inferior hemorrhoidal branch of 
the pudic, from the fourth and fifth sacral, and of the coccygeal 
nerves. These nerves supply the levator ani, sphincter, and 
coccygeus muscles ; the muscles of the perineum and clitoris are 
supplied by branches from the internal pudic, which nerve ter- 
minates in the nervous plexus of the glans clitoris. (Fig. 148.) 
The hypogastric plexus, derived from the sympathetic, lies be- 
tween the common iliac arteries, and distributes branches, which 
are reinforced by others from the lumbar and sacral ganglia 
and sacral nerves, to form the inferior hypogastric plexuses, 
one of which is situated on each side of the vagina. These 

14 



210 



GYNECOLOGY. 



plexuses distribute filaments to the vagina, uterus, Fallopian 
tube, and ovary. The pelvic, splanchnic, and hypogastric 
nerves are motor and sensory to the bladder ; the pudic is motor 




Fig. 148. — Nerves of the Unimpregnated Uterus with the Nerves of the Clitoris. 

— (Savage.) 

I. Hypogastric plexus. 2. Rectal branch of inferior mesenteric plexus. 3. A 
lumbar ganglion of the sympathetic. 4. Spermatic plexus, supplies Fal- 
lopian tube, ovary, and part of the uterus. 5. Branches from third and 
fourth sacral, aiding to form 6, 7, right inferior hypogastric plexus. 8. 
Uterine filaments. 9. Vesical plexus and branch. 10. Trunk of great 
sacrosciatic nerve. 11. Muscular branch of the fourth sacral nerve. 12. 
Trunk of pudic nerve. 13. Continuation of 12 into dorsal nerve of the 
clitoris. R. Rectum. U. Uterus. B. Bladder. D. Transversus perinei 
muscle cut across. S. Section of ilium. P. Section of symphysis. 



ANATOMY. 211 

to the sphincter; and all the nerves of the vagina and clitoris 
are sensory to the skin of the perineum, and especially so to the 
mucous membrane of the glans clitoris. The terminal filaments 
in the uterus are found in the nuclei of the unstriped muscle. 
Those of the mucous membrane are said to end in ttie ganglia. 
End-bulbs have been found in the clitoris and vagina. In the 
ovary the nerves pass to the Graafian follicle and to the walls 
of the membrana granulosa. 

279. Consideration of the Pelvic Organs and Structure 
Studied as a Whole. — In the upright position the plane of the 
brim of the pelvis is at an angle of 60 degrees to the horizon. 
The fundus of the uterus lies just below this plane, with its 
axis at right angles to it, and consequently at right angles to 
the vagina, which is parallel to the brim of the pelvis. In 
the upright position the internal abdominal pressure is directed 
against the symphysis and the posterior surface of the fundus 
of the uterus when in its normal situation. 

The uterus, as we have seen, is freely movable — swung 
in its position in the pelvis by the ligaments. The broad liga- 
ments maintain it in the center of the pelvis, and by their position 
and relation serve to assist in maintaining it in an antefiexed 
position. The round ligaments are an additional stay, and 
when of normal resiliency, draw the fundus forward. The 
other ligaments are the uterovesical and the uterosacral. The 
former are formed by the reflection of the peritoneum from 
the bladder to the uterus; the latter, while consisting of folds 
of peritoneum, also contain muscle-fibers, which are derived 
from the superior muscular layer of the uterus. The function 
of the latter filaments is to hold back the cervix, while the 
intra-abdominal pressure maintains the fundus forward. De- 
viations from the normal inclination of the pelvis, from the 
normal resiliency and tone of the ligaments, from the proper 
relations and support of the vagina, increase in the weight 
of the uterus, and increased intra-abdominal pressure, are all 
factors in the production of uterine displacements, especially 
that form characterized by descent. The plane of the outlet 
of the pelvis when the patient is erect forms an acute angle 
in front with the horizon. The urethra, the vagina, and in 
the upper part of its course the rectum, are parallel to the 
plane of the brim of the pelvis. The lower portion of the rectum 
turns acutely backward and forms an axis at right angles to 
that of the vagina. This portion, the anus, looks backward 
and downward; consequently the introduction of the finger 
or of the nozle of a syringe must be directed forward and up- 
ward, or directly toward the vagina, and after passing into 
the anus, is carried upward and backward. On median vertical 



212 GYNECOLOGY. 

section the vagina will be seen to be a mere slit, slightly S- 
shaped, the lower part of which presents the convex surface 
of its posterior wall anteriorly. The pelvic floor is consequently 
divided into two segments, the anterior and upper of which 
rests upon the more fixed posterior segment. The rectum 
at the anus is found to form an anteroposterior slit. 

Intra-abdominal force first causes pressure of the anterior 
segment upon the posterior, and then a sliding backward of 
that portion of the inferior segment in front of the anterior 
wall of the rectum. 

PHYSIOLOGY. 

280. Functions. — The important functions of the genital 
organs are the processes associated w4th reproduction. These 
comprise the alterations in the organs by which menstruation 
is established, repeated monthly, and finally discontinued; 
the relation of the sexes in copulation; the fecundation of the 
ovum, its subsequent nutrition, and the procedure by which 
the matured product attains a separate existence. 

1. The transition from child to woman, indicated by the 
appearance of menstruation, is denominated puberty. 

2. The completion of development, which fits the individual 
for the processes of maternity, is called nubility. 

3. The deposit of the vitalizing principle of the male within 
the body of the female occurs through the act of copulation, 
and its union with the ovum is known as fecundation. 

4. The nutrition of this vitalized structure and its subse- 
quent course of development are recognized as gestation. 

5. The processes by which the matured product is afforded 
a separate existence are known as parturition. 

The first three of these divisions and their variations from 
the normal comprise the field of gynecology. 

281. Puberty. — The completion of the developmental proc- 
ess that results in the establishment of menstruation and 
ovulation has been called puberty. It marks the transition 
from the child to the w^oman, and occurs betw^een the thirteenth 
and fifteenth years. The age of the individual differs under 
varying circumstances. Puberty occurs earlier in the natives 
of hot chmates than in those of the north, and earlier in the 
Latin races than in the Anglo-Saxon. City girls mature at an 
earlier age than those raised in the country, and those raised 
in affluence sooner than the poor. The occurrence of the phe- 
nomena of menstruation prior to the age of thirteen is called 
precocious puberty. Such instances are not infrequent. Iso- 
lated cases occur in which it appears at a very early age. Rein 



PHYSIOLOGY. 213 

reports the case of a girl of six years whose pubes were covered 
with hair and who menstruated regularly for a year. The 
*'New York Medical Record," i6, xi, 1895, presents a report 
of a girl who gave birth to a child when ten years of age. 

Retarded or delayed puberty is caused by chlorosis, plethora, 
or some congenital condition of the genital tract. Numerous 
cases are recorded where women have given birth to children 
prior to the establishment of menstruation; in other words, 
ovulation occurs without the usual manifestation. 

The advent of puberty is manifested by other characteristics 
than menstruation. The figure becomes more rounded, from 
an increase of adipose tissue. The breasts enlarge and fre- 
quently become painful. Hair grows upon the mons veneris 
and labia majora. Under this process occurs increased blood 
formation, the development of glandular structure, particularly 
in the uterus and the mammary gland, and, especially, marked 
changes in the nervous system. "There is," Christopher 
Martin says, " a remarkable transformation in the psychic, 
emotional, and mental life of the girl. The current of her 
thoughts is mysteriously changed. Hopes and yearnings un- 
known before thrill and agitate her, and life acquires a new 
and deeper meaning. These profound and subtle changes 
are not so difficult to understand if we accept the view that 
puberty means the sudden bursting into activity in the midst 
of the nervous system of a hitherto dormant center." 

The glandular development of the mamm^ may be so rapid 
and at times so irregular as to simulate a tumor. The period 
of life should prevent error. 

282. Nubility. — The advent of puberty indicates that the 
conditions and functions are established that will permit pro- 
creation, but the structures are not sufficiently developed 
to render the individual suited for favorable reproduction. 
Experience has demonstrated that the mortality is much greater 
among those who come to the completion of gestation prior 
to the age of twenty. Women coming to early maternity 
mature early, reach the menopause at an early age, and are 
prematurely aged. 

283. Menstruation and Ovulation. — Menstruation — also called 
the menses, the monthlies, the courses, the turns, the sickness, 
and the periods — has been defined by Sutton as the ''periodic 
discharge of blood from the uterus, accompanied by the shed- 
ding of the epithelium of the body and fundus, as well as of 
that lining the utricular glands near their orifices." 

Ovulation is the discharge of an ovum from a matured Graa- 
fian follicle. These two processes are considered here in co-rela- 
tion, though we have no positive proof that they are co-depen- 



214 GYNECOLOGY. 

dent. We have, however, determinative evidence that they are 
occasionally independent of each other. The not infrequent 
occurrence of pregnancy prior to the advent of puberty and sub- 
sequent to the climacteric is an indication that ovulation can 
occur without menstruation. 

The recent investigations of Frankel seem to justify him in the 
presentation of the following theory regarding the corpus luteum 
and its influence upon the menstrual function: i, the corpus 
luteum is a gland with an internal secretion capable of being 
always formed afresh in the (functional) ovary; 2, the corpus 
luteum carries psychic nutritive impulses to the uterus, especi- 
ally as concerns the endometrium, in the connective tissue of 
which it excites extreme hyperemia and hyperplasia ; 3 , it effects 
the adhesion of the impregnant ovum, or, failing this, it excites 
menstrual secretion. The acceptance of the above hypotheses 
renders the periodical occurrence of menstruation and its varia- 
tions more intelligible than any other which has been presented. 

Menstruation, in the majority of women, occurs every twenty- 
eight days, and the flow lasts from two to eight days. The 
intervals may vary from twenty-one days to five or six weeks. 
It does not always occur at an absolutely definite date in the 
same individual. 

The quantity of blood lost is diflicult to determine. The 
average amount is estimated at from three to five ounces. It 
has been mentioned that the flow varies in duration from two to 
eight days. A flow shorter than two or longer than eight days 
in duration indicates an abnormal condition. Absent or greatly 
decreased flow is known as amenorrhea. The prolonged or ex- 
cessive flow is called menorrhagia. When the function is asso- 
ciated with severe pain, it is pronounced dysmenorrhea. The 
menstrual discharge is not pure blood, but consists of a dark 
bloody fluid, thin and slimy in character, which contains, as 
revealed by the microscope, blood-corpuscles, leukocytes, epi- 
thelium, and stroma. The normal menstruation is not clotted, 
due to the admixture of the secretion of the uterine and cervical 
glands. It is only when the flow is excessive or the gland secre- 
tion deficient that clots are present. 

Menstruation occurs only in women and in certain monkeys ; 
it is apparently limited to those animals that maintain the erect 
position. 

Menstruation involves between thirty and thirty-five years 
of the life of the woman, known as the period of active sexual 
life, beginning from the thirteenth to the fifteenth years and 
continuing from the forty-fifth to the fiftieth. The final cessa- 
tion, like its advent, may be advanced or retarded by various 
causes. Each menstrual period is generally preceded by some 



PHYSIOLOGY. - 215 

premonitory symptoms, a sense of Aveight, pressure, or uneasi- 
ness extending down the limbs, a sense of exhilaration, an in- 
creased vascular tension, and, Belfield asserts, an increase of 
weight which may exceed one pound an hour for several hours, 
the woman gaining seven to nine pounds in twenty-four hours. 
This increment, he says, is due, i, to increased absorption of oxy- 
gen, and, 2, to decreased elimination. With the establishment 
of the flow she suffers from depression, languor, malaise, dis- 
inclination for exertion, either physical or mental, and, according 
to Belfield, decrease in weight. Alany women will exhibit a 
tendency to the occurrence of gastro-intestinal disturbance, 
formation of toxins developing an autointoxication, which will 
produce migraine, aggravate nervous manifestations, chorea, 
epilepsy, and will cause delusions. Epilepsy and insanity are 
frequently so marked and recur so regularly Avith the menstrua- 
tion as to lead the family and physician to believe the disorders 
are the result of diseased conditions of the pelvic organs. 

During the menstrual process the uterus and pelvic viscera be- 
come engorged Avith blood; the uterus is enlarged, turgid, and 
sensitive; the capillaries rupture, some upon the surface and 
others Avithin the mucous membrane. The uterine epithelium be- 
comes desquamated ; during the process of engorgement the glands 
have become filled with epithelium, which is discharged from 
the external portion of the gland. Many of the cells are lique- 
fied, increasing the quantity of mucus. With the establish- 
ment of the floAv the engorgement is relicA^ed and the general 
disturbance subsides. After the termination of the period 
the mucous surfaces are gradually regenerated from the epi- 
thelial tissue remaining in the glands, until, at its culmination, 
the process is again rencAA^ed. According to Napier, this des- 
quamation and regeneration of the structures from the utric- 
ular glands, and the accumulation of glandular products in 
the uterine glands and the OA^aries, stands in a causative relation 
to menstruation. The menstrual discharge is suppHed by the 
entire cylindric epithelium-lined mucous membrane. ]\Iy own 
researches, confirmed by those of many others, are sufficient 
to demonstrate that the Fallopian tubes as aa^cU as the uterus 
take part in the menstrual flow. It is not unreasonable to sup- 
pose that the presence of bloody fluid in the tube is of value in 
promoting the nutrition of the fecundated ovum and that the 
consequent distention of the tube facilitates the passage of the 
ovum to the uterus. Many ingenious theories for the recurrence 
of menstruation haA'e been advanced, but Avhether we accept 
the hypothesis advanced by Frankel or not, it can not be denied 
that the ovaries are its cause, for the following reasons: i. The 
ovary furnishes the ovum, which it is the function of the uterus 



216 



GYNECOLOGY. 



to retain and nourish until its product is ready for a separate 
existence, hence the producer rather than the retainer should 
dominate the function; 2, the entire removal of ovarian struc- 
ture invariably results in the cessation of menstruation; 3, the 
removal of the ovaries is general^ followed a couple of days 
later by the occurrence of a vaginal discharge which can not be 
distinguished from the ordinary menstruation. The discharge 
is undoubted^ due to the pressure of the ligature upon the nerves 
which supply the ovaries; 4, Strassman's experiments of in- 
jecting the structure of the ovary with sterilized water were 







Fisf. 



149. 



-Changes of Uterine Mucous Membrane During Menstruation. 
(Wyder.) 



follow^ed two days later by a discharge from the uterus which 
in every way resembled menstruation. The occasional occur- 
rence of bloody discharge after the removal of both ovaries has 
been held to negative our second proposition, but my experience 
leads me to doubt the regular recurrence of menstruation after 
the complete removal of both ovaries. An occasional bloody 
discharge from the genital tract after the extirpation of both 
ovaries means nothing more than that there has been some 
local congestion which has been thus relieved. 



PHYSIOLOGY. . 217 

It is only when the ovaries and utricular glands attain a 
development that renders their secretion capable of exerting a 
dominating influence upon the general economy that puberty 
occurs, and the process continues until these structures begin 
to atrophy and cease to exert their governing course. Napier 
denies the probability of the period being induced by ovulation, 
and cites the occurrence of the latter without menstruation, 
and the continuation of menstruation after the removal of 
both ovaries, as presumptive evidence. Many other theories 
are advanced for the periodic occurrence of menstruation. 
Johnstone believes in a special menstrual nerve plexus, situated 
near the cornua of the uterus; but this structure has not been 
recognized by any other observer. 

The alteration of the uterine mucosa which occurs during 
menstruation prepares it for the reception and nutrition of 
the fecundated ovum. The fact that gestation occurs with- 
out an intervening period is no contravention of this supposition, 
but only a demonstration that the preparation can occasionally 
occur without the shedding of blood. 

The nen^e influence leading to the increase of the liquor 
foUiculi, and the liquefaction of the cells of the membrana 
granulosa, promote the multiplication of cells in the mucosa 
which is followed by menstruation. The coexistence of these 
processes is seen in the formation of a corpus luteum syn- 
chronous with menstruation. The course of menstruation is 
averted by pregnancy. Menstruation continues during pregnancy 
only with the rarest exceptions, and the functional activity 
of the ovaries is suspended during lactation. Neither ovulation 
nor menstruation is likely to occur during lactation. Many 
women prolong the period of lactation for the purpose of render- 
ing themselves less susceptible to fruitful coition. 

Menstruation, it is seen, is one of the imiportant functions of 
the genital tract, hence diseased conditions of the internal geni- 
talia generally manifest themselves by disturbances of this 
function. 

The disturbances of the menstrual function are: amenorrhea, 
dysmenorrhea, menorrhagia, and metrorrhagia; and, we may 
add, vicarious menstruation. 

Amenorrhea is a term applied to an almost or complete 
cessation of bloody flow. Occasionally the vascular tension is 
insufficient to result in the rupture of vessels and the discharge 
of blood, but causes increased secretion from the uterine glands 
which, with the desquamated epithelium, produces a profuse 
leukorrhea that supplants the menstrual flow. 

Amenorrhea is congenital when puberty is much prolonged 
beyond the period of its usual occurrence, and is due to defective 



218 GYNECOLOGY. 

development, chlorosis, anemia, or mechanical obstruction; 
constitutional, when profound blood changes exist or diseased 
conditions are present which are calculated to reduce vascular 
tension; mechanical, when an obstruction, congenital or ac- 
quired, exists to prevent its exit ; due to disease of the ovaries, 
when these organs have become destroyed or their function has 
been arrested. Finally, it is a symptom of the existence of preg- 
nancy. 

Chlorosis and anemia, as factors in the production of amenor- 
rhea, are generally easily recognized by the appearance of the 
patient. Blood examinations will be of special value, however, 
to determine the degree of anemia and the extent and gravity 
of the defective development or the degenerative changes in the 
blood-corpuscles . 

Chlorosis generally occurs in the young. The patient may 
present an appearance of full flesh, but is white or greenish- white ; 
the lips are pale, and the ears transparent ; the pulse is rapid, and 
she breathes rapidly upon the slightest exertion. The menstrual 
flow is supplemented by the profuse leukorrheal discharge al- 
ready mentioned. Chlorosis and anemia may frequently be the 
precursors of tuberculosis, hence the wide-spread dread of this 
symptom upon the part of the laity. 

Disease of the ovaries, in the form of glandular cystoma of 
both ovaries, will sometimes result in this symptom. I say some- 
times, for it is only when the entire structure of the ovary has be- 
come disorganized that it occurs, and menstruation may con- 
tinue to be regular and pregnancy may occur when both OA^aries 
are the seat of cystomata. Another change in metabolism, due 
to ovarian disease, the pathology of which has not as yet be- 
fully recognized, results in an early menopause. The woman 
ceases to menstruate at thirty years or younger. She looks well 
She will give a history of rapid gain in flesh, thirty or forty pounds 
in a year, and of a gradual decrease in, or sudden arrest of, the 
menstrual flow. She may have had one or two childen or never 
have been pregnant. That the condition is not always as- 
sociated with destroyed function of the ovaries is evident from 
the fact that in some of these patients under regulated diet and 
suitable treatment the menstruation returns and the sterility 
is overcome. 

When amenorrhea is produced by mechanical causes, it may 
be primary or acquired, and the obstruction may occur at any 
part of the genital canal, although when in the tube it may not 
preclude an external flow, while resulting in a partial retention. 
Such a patient will present the appearance of good health, will 
exhibit periodically menstrual molimina, and later an abdominal 
swelling may become visible. In the primary form the patient 



PHYSIOLOGY. 219 

has never had a visible menstrual flow; in the acquired, there 
usually is a history of a diiScult or instrumental labor or some 
injury to the genital tract, after which there was no visjble flow, 
though efforts to menstruate had recurred. In both classes of 
cases the possibility of pregnancy should be considered and may 
be suspected, but in the primar}^ the patient should be given 
the benefit of doubt until examination has rendered pregnancy 
certain. 

The diagnosis will be difficult only when the obstruction is at 
the internal os. Even in such cases the distention of the uterus 
is likely to be more spherical, and the uterine wall thinner and 
yet more tense, than when the distention is due to pregnancy. 
Should the examiner be uncertain, he may postpone the diag- 
nosis for another month. 

The amenorrhea of pregnancy is generally easily recognized 
by the healthy appearance of the patient and the usual physical 
signs associated with pregnancy. 

Dysmenorrhea, as a symptom of pelvic disease, is the most 
frequent disturbance of the menstrual function, and, possibly, 
as a result of the training and manner of life of our women, is 
becoming more frequent. It indicates painful flow, consequently 
the expression of intermenstrual dysmenorrhea is a misnomer. 
We commonly make the classification into congestive or in- 
flammatory, obstructive or mechanical, ovarian, and nervous 
dysmenoiThea, but such an arrangement is misleading. It is 
very doubtful whether obstruction ever is much of a factor in 
its production. Some of the cases in which I have found dys- 
menorrhea most marked were in women in whom the uterus was 
very patulous and a sound could be carried to the fundus Avith- 
out any difficulty. On the other hand, Avomen with uncompli- 
cated antefiexions of marked degree have menstruated without 
pain. 

To appreciate fully the significance of this symptom we must 
remember that the uterus is an erectile organ, whose walls are 
subject, as in all other involimtary muscle structure, to rhythmic 
contractions. Any inflammation of this organ, whether in its 
mucous membrane, muscle-wall, or serous covering, must to a 
certain degree render the performance of the menstrual function 
painful. In cases in which the canal is patulous in the inter- 
menstrual inter\^als the myometrium is undoubtedly the seat 
of the inflammation, and the painful spasm resembles the oc- 
currence of chordee in the male. This symptom is provoked or 
aggravated by faulty or defective development of the uterus, by 
flexions, chronic metritis, perimetric inflammation, rheumatism, 
gout, and neurasthenia. Its existence demands careful investi- 
gation for its cause, and it should not be forgotton that frequently 



220 GYNECOLOGY. 

much more will be accomplished by the treatment of the con- 
stitutional condition than by local applications. The experienced 
physician has recognized that the neurasthenic patient will often 
perform none of her functions painlessly, and it can be readily 
appreciated that such a patient will require but little disturbance 
of the pelvic organs to occasion pain during the course of menstrua- 
tion. Ovarian dysmenorrhea is hardly an appropriate term, for 
the reason that the ovarian pain is usually felt with greatest in- 
tensity some days or a week prior to the flow, and should be 
considered as an indication of chronic inflammation of those 
organs. 

Recently much attention has been directed to the theories 
of Fleiss and Schijff as to the nervous or reflex dysmenorrhea 
attributed to what are denominated the genital spots in the nose. 
The mere fact that cocain solution can be applied to the nasal 
mucous membrane and afford relief is not proof positive that the 
surface thus touched was the cause of the symptom. Cocain 
given internally or hypodermically would be equally effective, 
but is not a safe remedy for frequent employment. 

Membranous dysmenorrhea is a form of painful menstruation 
in which a more or less well-defined cast of the uterus is discharged. 
It is usually associated with pain as intense as if the woman were 
undergoing an abortion. The cast contains the epithelial layer 
of the endometrium, often showing partial casts of the gland 
tubules, and also contains a croupous exudate. We need but 
to recur to the phenomena of menstruation with its desquamated 
epithelium to appreciate that this condition is the result of a more 
severe and chronic inflammation. 

The condition is recognized by the association, with labor-like 
pains, of the discharge of shreds of membrane or an entire cast 
of the uterine cavity. The false membrane may occur but occa- 
sionally or at every period. Its occurrence indicates lowered 
vitality and a profound neurotic state. 

Menorrhagia and metrorrhagia are terms used to indicate, 
respectively, excessive menstrual flow at the regular periods and 
bloody flow without any periodicity. The symptom may begin 
as menorrhagia and end in metrorrhagia. It may occur at any 
time between puberty and the menopause, and metrorrhagia 
may follow the latter. The symptom may be the result of con- 
stitutional conditions interfering with vascular tension, either 
locally or generally, as in hepatic, cardiac, or renal disease, caus- 
ing obstruction in the zymotic fevers, scurvy, and other con- 
stitutional conditions. It may be produced by pelvic conditions 
outside the uterus, as in cystic degeneration of the ovaries, in- 
traligamentary cysts, flbroid growths, ectopic gestation, or peri- 
uterine inflammation; from uterine involvement, as in threat- 



PHYSIOLOGY. 221 

ened abortion, retained fetal products after labor or abortion, 
interstitial inflammation of the uterine mucosa, interstitial or 
submucous myomata, malignant conditions, such as epithelioma 
of the cervix, adenocarcinoma of the cervix or body, endothelioma, 
sarcoma, or chorioepithelioma. 

Vicarious menstruation indicates a discharge of blood from 
some other surface than the uterine endometrium. It may occur 
from the nose, ears, anus, or nipples, or as petechia or purpura 
beneath the skin. Its occurrence is readily understood when 
we consider the preparation for the menstrual flow characterized 
by increased vascular tension. The vessels which are weakest 
are the first to rupture, and the released tension prevents the 
rupture of the endometrial vessels, hence the absence of the genital 
flow. The symptom is recognized by its periodicity and the 
absence of regular menstruation. 

284. Menopause. — The conclusion of menstrual activity is 
recognized as a critical period in the woman's existence. It is 
variously denominated the menopause, the climacteric, and the 
change of life. The menstrual life of the woman lasts, upon an 
average, nearly thirty-five years, so that the menopause should 
occur between the forty-seventh and the fiftieth years. Its 
occurrence may be accelerated or retarded by various causes. 

Premature menopause occurs prior to the age of thirty-two, 
and may be induced by shock, severe illness, prolonged anxiety, 
overstudy, mental affections, disease of the ovaries, — such as 
destruction of the ovarian stroma by double ovarian tumors, — 
sepsis, chronic disease of the appendages, and some forms of 
metritis. 

Early menopause occurs between the ages of thirty-two and 
forty-two. It occurs early in the virgin, and earlier in blonds 
than in brunets. Fat women reach the menopause early. A 
rapid increase in adipose tissue is associated with some cases of 
premature menopause. Occasionally the menopause occurs at 
an early age without any assignable cause. 

Retarded or Delayed Menopause. — The occurrence of the meno- 
pause is distinctly affected by heredity. 

It may be delayed by child-bearing, by the presence of uterine 
growths, and by the presence of malignant degeneration. Rob- 
ertson reports the case of a woman who ceased to menstruate 
for twelve months at the age of fifty, when the flow returned 
and continued until her death at seventy. Saxonia speaks of a 
nun who had a return of her menstruation at the age of one hun- 
dred, which continued regularly until she died three years later. 

The term menopause is employed to designate the period of 
the change. The average duration of the menopause is about 
two and one-half years. A few fortunate persons continue to 



222 GYNECOLOGY. 

menstruate regularly until a certain period, when the flow dis- 
continues, never again to recur. Others continue irregular for 
six months, when it ceases. Generally a patient will notice that 
the periods are getting more scant, until finally she misses one 
or two periods; then menstruation recurs for a while, to again 
subside, thus continuing irregularly for one or two years. The 
irregularity may be prolonged over a period of four or five 
years. While, as a rule, the intervals are longer, the periods 
may occur more frequently, with intervals of but twenty-one or 
even fourteen days. 

The flow may be increased, and occasionally hemorrhages 
occur without any assignable cause. 

Excessive or prolonged bleeding should always be a cause of 
anxiety, and should lead to a careful examination in order to 
determine its cause. The cause should not be assigned to change 
of life until careful investigation has eliminated every other 
source. The occurrence of menstruation is attended with the 
elimination of certain materials from the blood. 

Chemic changes in the blood and tissues are constant, and the 
elimination of the albuminoids during menstruation is demon- 
strated by a more marked alteration of the blood following 
menstruation than the mere blood-loss would produce. 

When menstruation is arrested by anemia or pregnancy, we 
see in the skin marked deposits of pigment and other materials 
that would be eliminated by its occurrence. 

When the menopause occurs suddenly, the retained products 
produce an intoxication which results in various nervous per- 
versions. It is a very usual occurrence to witness various vaso- 
motor disturbances, such as sudden sensations of heat; flushings; 
waves of blood rolling up to the face, accompanied by a sensation 
of giddiness, suffocation, or oppression; cold, clammy perspira- 
tion ; shooting neuralgic pain ; headaches ; fullness of the vessels 
of the head and neck ; palpitations ; gastric irritation ; diarrhea ; 
irritability of temper; melancholia; and disturbed mental bal- 
ance. 

In sudden production of the climacteric after radical opera- 
tions the vasomotor disturbances are frequently so distressing as 
to render the condition for which the operation was performed 
preferable. 

Treatment. — The more distressing vasomotor disturbances can 
be ameliorated by the employment of tonics, good food, rest, 
massage, and the application of the galvanic and Faradic cur- 
rents; the administration of the bromids, asafetida, and other 
nerve sedatives ; the regulation of the bowels ; and the promotion 
of digestion. 

Picrotoxin in -^-grain doses three times daily seems to exert 
a specific influence in some cases. 



MALFORMATIONS. 223 

285. Copulation is that act of union of individuals of the 
two sexes by which the vitaHzing principle of the male is depos- 
ited in the genital organs of the female. The sexual desire of 
the woman is much less marked than that of the man. Fre- 
quently she has no sexual sensation, and the act is even repug- 
nant, but she yields to the man's embrace from her wish to 
gratify his desire. Such a woman, mated to a man of impetuous 
inclination, often becomes a sexual slave. The clitoris and the 
tissues about the vestibule are erectile, and take part in the 
orgasm, during which a secretion is ejected from the vulvo- 
vaginal glands. 

Imperfect or unsatisfactory coptilation is a prolific source of 
disease. Efforts to avoid the legitimate results of copulation, 
like all violations of nature's laws, visit their penalty upon both 
the offenders, but most heavily upon the woman. 

286. Fecundation. — The union of the spermatozoid with the 
ovum and the successful fertilization of the latter are known as 
fecundation. Its occurrence does not require that the woman 
should share in the pleasurable sensation of copulation; indeed, 
it can follow in spite of the fiercest resistance upon her part. 
The spermatozoids, the active fertilizing agents from the man, 
require no assistance from the woman, but by a vermicular 
motion can make their way to the ovum in the internal organs. 

There has been much discussion over the probable point 
at which fertilization occurs and as to the ability of the sper- 
matozoa to penetrate the narrow isthmus of the Fallopian 
tube against the waving cilia, the function of which is to pro- 
mote a current toward the uterus. The demonstration that 
they do overcome these obstacles in the sheep and other lower 
animals, and are found swarming over the ovary, and the fre- 
quent occurrence of ectopic gestation in the woman, should 
be accepted as a sufficient demonstration that they make the 
voyage. It is most probable that fecundation results in the 
tube, from which the vitalized ovum passes into the uterus, 
which is prepared for its reception. 

Impregnation is more likely to occur during or immediately 
following menstruation; less likely, immediately preceding the 
flow ; and the woman is least susceptible in the mid-interval. 

Independent of organic conditions, there is a marked differ- 
ence between individuals as regards their susceptibility to im- 
pregnation. 

MALFORMATIONS. 

287. Classification; Definition. — A genital malformation is 
any deviation from the normal form and structure of the fe- 



224 



GYNECOLOGY. 



male reproductive organs. As the processes of development 
are not completed until puberty, such deviations may arise 
from the arrest or distortion of growth at any one of the periods 
we have already considered in the study of the formation of 
these organs. As the majority of instances of abnormality 
are due to prenatal causes, they are justly considered, there- 
fore, as congenital. In a former edition I considered the various 
lesions of parturition under the head of acquired malformations, 
but will now discuss them under the designation of traumatisms. 
288. Bifidities. — The development of the uterus and vagina 
from the coalescence of the two Mullerian ducts naturally 






Fig. 150. — Degrees of 
Division of the 
Genital Tract. 



Fig. 151. — Uterus Bicornis. 



leads, upon arrest or faulty continuation of the process, to a 
-partial or a complete separation of these organs into two canals. 
Such a bifid development may be either equal or unequal. 
This double development may result in the formation of two 
canals by a simple partition or septum through what seems 
one body, or a partial or complete separation into two bodies. 
289. The Degrees of Division. — The most frequent form 
of malformation is the presence of a more or less complete 
septum between the two sides of the uterus and vagina. This 
partition or septum in the uterus may, according to its extent, 
consist of five degrees. The first (I, Fig. 150) will present 



MALFORMATIONS. 



225 



a mere outline which projects from the fundus. Such a con- 
dition is rarely recognized during life, unless opportunity is 
afforded for digital exploration of the uterine cavit3r: In the 
second degree (II, Fig. 150) a septum extends through the body 
to the internal os. This form can be recognized following 
delivery or abortion, but otherwise may give no indication of 
its presence. The occurrence of pregnancy may cause its 
destruction. In the third degree (III, Fig. 150) the body and 
cervix are divided by the septum into two distinct canals. 
The fourth degree (IV, Fig. 150) affords a septum, which is 
incomplete only in the vagina, and the fifth (V, Figs. 150 and 
158) presents a complete uterovaginal septum, forming two 




Fig. 152. — Uterus Bicomis Unicollis. 



canals. The one canal may be readily overlooked, or coition 
may occur in either side indifferently. 

290. Double Uterus. — The division of the organ into two 
portions may be more or less complete, and consequently may 
form three classes : • 

First, the division of the fundus by a groove and two lobes, 
known as the uterus bilobularis, uterus bicornis arcuatus, or 
uterus bicornis unicollis (Fig. 151), the latter especially when 
but one cervical canal exists (Fig. 152). 

Second, the body divided into two distinct portions, the 
double uterus bicornis (Barnes) — uterus bifidus; it may have 
a single or two cervical canals (Fig. 153). 

Third, two separate organs exist, each with one tube and 
ovary, uterus didelphys (Fig. 154). The bodies diverge, each 

15 



226 



GYNECOLOGY. 



half being held to the corresponding side by the short broad 



ligament 




Fig. 153. — Uterus Bitidi 




Fig. 154. — Uterus Didelphys. 

291. Unequal Development of the Two Sides. — The two 

canals of Muller may be incompletely developed, and thus 



MALFORMATIONS. 



227 



produce asymmetric organs of varying form. The one canal 
may be completely atrophied, while the other presents a well- 




Fig, 155. — Uterus Unicornis. 



developed horn — the uterus unicornis. (Fig. 155.) Generally, 
the absence of one horn is associated with absence of the corre- 
sponding tube and ovary. The horn may be rudimentary 
or partly developed, per- 
mitting the occurrence of 
menstruation and even 
pregnancy. Such a horn 
is not generally prepared 
for the maintenance of 
the fecundated ovum to 
the completion of gesta- 
tion, and may result in 
rupture prior to the sixth 
month. In some cases 
the occurrence of such 
a pregnancy is quite as 
dangerous to life as a 
tubal gestation, from 
which it can not, pre- 
vious to operation, be 
differentiated. I have 
seen instances in which 
a one-horned uterus had 
passed successfully 
through more than one 
pregnancy and the ab- 
normal condition was only discovered by accident. Atresia in 
the canal of a rudimentary or partly developed horn may exist, 
and lead to an accumulation of the menstrual secretion and the 




Fig. 156. — Atresia of Rudimentary Horn with 
an Accumulation of Menstrual Blood. 



228. GYNECOLOGY. 

formation of a tumor. (Fig. 156.) The diagnosis of such a con- 
dition is exceedingly difficult, and can be determined only during 
an operative procedure. The accumulation may rupture into the 
vagina, but usually at such a height as to leave a portion of the 
sac dependent and undrained, and, therefore, likely to become 
infected and lead to septicemia. When the condition is recog- 
nized, the treatment should be that for retained menstruation, 
which will be described later. The development of a one-horned 
uterus may be associated with a double cervical canal, — uterus 
biforis, — a condition which may cause embarrassment during 
labor. The septum when discovered may be pushed to one 

side, or, if necessary, be cut 

^ ^^v between two sutures (Pozzi). 

flw '^9 When torn, it has caused 

^Ki^ /^jlL severe hemorrhage. 

|H^^^ /^f^^i ^9^* Absent Uterus. — En- 

«|H^^^|^^^>'h^ .^^ "f tire absence of the uterus is 

^S^gH^HpB rare, and is almost always 

^^^W^^^^ associated with absence of 

i / the other genital organs, 

: / ^ particularly of the vagina. 

A' i^ The determination of the 

" ^ , jl' condition is difficult. 

V i '^ 9 I ^^^ introduction of the 

I I 5 B y index-finger of one hand into 

I > the rectum, and that of the 

other or of a catheter into 
^ the bladder, enables the op- 

S'- erator to explore thoroughly 

•^ ^^ the pelvis. Failure to recog- 

nize the organ may be due to 
its rudimentary condition or 
Fig. 157.— Uterus Bipartitus or Duplex, i^s displacement to One sidc, 

and we can assert its entire 
absence only when we liaA^e been able to explore the pelvis 
through an abdominal incision or during an autopsy. 

293. A rudimentary uterus may exist in the form of a sHght 
thickening over the surface of the bladder, as two undeveloped 
canals in the form of a T, — the uterus bipartitus (Fig. 157), — 
when the vagina is frequently absent or may be partly developed, 
deepened by coition, or may exist as a small culdesac continuous 
with the urethra, which has been dilated by repeated efforts 
at coition. Menstruation is generally absent; ovulation may 
occur without molimina, or there may be the occurrence of 
hematometra. 

When the vagina is well developed and menstruation occurs. 



MALFORMATIONS. 



229 



the condition may remain undiscovered. The rudimentary 
character of the organ can be determined by bimanual palpation 
or by palpation through the rectum and the bladder, as has been 
described. The occurrence of painful molimina may require 
castration. 

294. Fetal and infantile uteri are instances in which the organ 
has been arrested during the fifth stage of its development. The 
uterus is small, the cervix two or three times the length of the 
body, and an acute anteflexion of the body probably exists. 

The infantile uterus differs from the fetal in that the arbor 
vitag arrangement of the mucous membrane no longer extends 
to the fundus. Menstruation rarely occurs, and sexual desire 
may be absent. The external 
genitals may be poorly or well ^ 

developed. The breasts not -^17 ^^-^ 

infrequently are normal. 

Treatment. — The existence 
of a malformation is an indica- 
tion of defective development 
and presents a condition in 
which the function of the af- 
fected organ must be more or 
less impaired. 

The presence of a septum 
through the uterus and vagina 
may be a cause of dyspar- 
eunia, due to the diminished 
size of the vaginal canal. It 
need not produce distress or 
danger during gestation, but 
not infrequently the cervical 
and vaginal septa may cause 
dystocia. 

The vaginal septum should 
be cut through its entire 

length and the edges of each wall sutured to prevent readhesion. 
The division of the septum by the thermocautery has been advo- 
cated as saving the time necessary for suturing. The cervical 
septum can be crushed by forceps, which should be left 
in place to produce necrosis of the compressed tissues. Such 
septa do not generally withstand the first gestation, but are 
broken dowm in the course of labor. I have twice seen a bridle 
of tissue attached to the lower portions of the anterior and 
posterior vaginal walls, which were without doubt remnants of 
an originally more complete septum. 

The division of the uterus into two equally developed por- 




Fig. 158. — Uterus Biseptus. 



230 GYNECOLOGY. 

tions does not usually call for treatment. The investigation of 
a large number of such cases demonstrates that pregnancy has 
frequently occurred without appearing to produce difficulty in 
parturition. This necessarily depends upon the development of 
the separate cornua. 

In one patient upon whom hysterectomy was done for inter- 
stitial myomata her history revealed that she had given birth to 
two children, apparently without any unusual phenomena. The 
operation disclosed that she had a rudimentary horn upon one 
side, which had its own cervical canal and opened into a blind 
pouch for a vagina, which was situated between the existing 
vagina and the bladder. 

It is my purpose upon the next opportunity to split the adjoin- 
ing cornua of a partially bifid uterus, and after coaptating their 
edges, suture the surfaces so as to establish one cavity. It may be 
questioned how such a reconstructed organ will endure the course 
of a gestation, but if pregnancy can go to full term in one horn 
of the uterus, the organ thus formed should be more capable of 
performing its physiologic functions. Where the uterine cornua 
are unequally developed, the danger is from conception occur- 
ring in the rudimentary cornu. The recognition of the exist- 
ence of such a pregnancy should be considered ample justifica- 
tion for its extirpation by operation. Where both cornua are 
rudimentary and the patient suffers from menstrual molimina, 
the abdomen should be opened and the ovaries removed. Simi- 
lar advice is proper when the uterus is absent. 

The fetal and infantile uteri frequently present conditions 
in which the function of menstruation is performed irregularly 
and attended with severe pain. The probability of the patient 
becoming pregnant and carrying the fetus to full term is depend- 
ent upon the degree of development. Under the stimulation of 
the marital relation such uteri occasionally increase in size. 
More frequently the individual complains of irregular and painful 
menstruation and is sterile. 

295. Congenital prolapsus uteri is an exceedingly rare con- 
dition, and is usually associated with other forms of defective 
development, as spina bifida. 

296. Accessory or trifid uteri have been reported. Hollander, 
in 1894, found a second uterus lying in front of the normal organ, 
between it and the bladder. It was a simple cervix with two 
orifices, having neither adnexa nor round ligaments. Depage 
describes a trifid uterus which probably arose from a diverticulum 
of one of the ducts of Miiller. 

297. Absent or Rudimentary Tubes. — Absence of the Fal- 
lopian tubes is a rare occurrence, and is associated with a similar 
condition of the ovaries and uterus. The absence of one tube is 



MALFORMATIONS. 231 

of more frequent occurrence; a unicornate uterus is generally 
found. A rudimentary tube is generally the result of an attack 
of fetal peritonitis. The tube may be a simple cord and yet 
have well-developed fimbria. The fimbria may be independent 
of the openings. 

298. Accessory tubal ostia are frequent. Ferraresi found six 
openings upon one tube, all of which were surrounded by fimbria. 
These openings are generally near the end, but may occur near 
the middle of the duct. They are probably due to failure in 
closure of the groove in the germinal epithelium or to splitting 
of the Mtillerian duct after it has closed. 

299. Anomalies in Length. — The normal tube is from ten 
to twelve centimeters long; in ovarian or broad-ligament cysts 
and in ovarian hernia one tube may be found from sixteen to 
eighteen centimeters long. 

300. Absent or Rudimentary Ovaries. — Absence of ovaries 
is an exceedingly rare condition, requiring an inspection of the 
abdominal cavity to confirm the suspicion. Absence of one is 
less rare, and is associated with a unicornate uterus, and occasion- 
ally with absence of the corresponding kidney. The rudi- 
mentary state is more frequent, and may be fetal or adult. It 
may contain no glandular tissue, or the presence of unclosed 
Pfiiiger's tubes may lead to a suspicion of a testicle. The con- 
dition may be produced by oophoritis or peritonitis during fetal 
or adult life, or by the twisting of a pedicle. 

301. Supernumerary ovaries are very rare. Von Winckel 
found a third ovary in front of the uterus. Tufts of ovarian 
stroma have been described. The occurrence of menstruation, 
and even of pregnancy, after the supposed removal of both 
ovaries has been reported, but it is more probable that in all 
such cases there has been failure to remove the entire structure 
of both glands. 

302. Accessory or constricted ovaries are more frequent. 
A portion of the ovary may depend from the main body by 
a more or less well-marked pedicle; as many as two or three 
have been found associated with one ovary. 

303. Displacements. — The descent of the ovary may have 
occurred, and the organ may be situated above the brim of 
the pelvis. The presence of the ovary in the sac of a hernia 
is a lesion often difficult of accurate recognition and productive 
of serious distress. 

304. Defects of Round or Broad Ligaments. — Absence of 
the round ligament is generally associated with absence of the 
uterus in whole or in part. I saw one patient in whom the 
muscular structure of the round ligament was completely ab- 
sent. The fold of the broad ligament, in which the round 



232 



GYNECOLOGY. 



ligament would lie, presented a thin, corrugated margin. The 
persistence of the canal of Nuck results in the formation of a 
hydrocele, which may attain to considerable size in the labia 
majora. The broad ligaments may be absent, extremely short, 
or unequal in length and thickness. They may contain cysts, 
which are relics of the parovarium. 

305. Complete Absence or Rudimentary Development of 
the Vagina. — In complete absence of the canal no trace of 

vaginal tissue will be 
found between the rec- 
tum and the bladder. 
These tw^o organs lie in 
contact, with connective. 
tissue only intervening. 
(Fig. 159.) In the rudi- 
mentary vagina a fibrous 
cord may exist, indicat- 
ing the site of the ducts 
of M filler, the develop- 
ment of which has been 
arrested in an early stage 
of fetal life. We may 
have a complete absence 
of one of the segments of 
the vaginal canal, with 
an incomplete develop- 
ment of the other. In 
these cases of absent or 
rudimentary vagina the 
uterus may be entirely 
absent, reduced to a rudi- 
mentary nodule, or more 
or less defective in its de- 
velopment. Rarely will 
a well-developed uterus 
be found associated with 
. absence of the vagina. 
In some patients normal 
ovaries: are present without any manifestation of menstrual moli- 
mina. Occasionally, there are periodic pains at the times of ovula- 
tion. Cases have been reported of vicarious hemorrhages from dif- 
ferent portions of the body, associated with extreme pains at the 
supposed menstrual periods, when a well-formed uterus was 
present. The vulva may also be absent, but is more frequently 
well formed, presenting a funnel-shaped depression behind 
well-developed nymphae. The hymen may be perfectly normal 




Fii 



159- 



-Absent VaRina. 



MALFORMATIONS. 



233 




and the urethra at times may be dilated by the efforts that have 
been made to effect coition. It is difficult to determine why it 
should be the lower portion of the vagina that most frequently 
is present in cases of arrested development. It is probably due to 
an abnormal elongation of the vestibular canal. This pouch, 
in the absence of the vagina and uterus, has been found to 
be two or three centimeters in length and sufficiently wide to 
admit the finger. These dimensions are very considerably 
increased by sexual efforts. The opening is generally closed by a 
pearly, reticulated membrane 
with a cicatricial appearance. 
The central portion of the vagina 
may be absent, or the two por- 
tions may be separated by a 
membrane of variable thickness, 
Avhich at times is perforated. 
One patient came under my ob- 
servation in whom there was a 
membrane dividing the upper 
and lower halves of the vagina, 
and a small opening situated at 
one side, which permitted the 
menstrual discharge to escape. 
The incision of this membrane 
exposed a good-sized cavity 
above, and by cutting out a por- 
tion of this septum, the two 
mucous membranes of the upper 
and lower halves were sutured 
together, to form a good-sized 
vagina. In patients w4th absent 
vagina the condition should be 
determined by a finger in the 
rectum and a catheter or a sound 
in the bladder. Combined rectal 
and vesical touch enables us to rec- 
ognize the presence of the uterus 
and its degree of development. 

Treatment. — x\bsence of all or a part of the vagina affords 
different indications according to the development of the uterus. 
If the latter organ is normal and the symptoms of menstrual 
molimina have existed, with a uterus increased in size, the 
presence of hematometra should be suspected, and interference 
should be employed. If there is no uterus and well-developed 
ovaries are present, associated with painful sensations, the 
condition may be considered a sufficient indication for cas- 




Fig-. 1 60 



Line of Incision for For- 
mation of Flaps. 
Flaps from labia minora which 
are split and used to line the 
vagina. 



234 



GYNECOLOGY. 



tration. Absent vagina renders the person sexually incom- 
petent, and it becomes a serious question as to whether a vagina 
shall be established for sexual purposes. The operation for 
the formation of a vagina was first performed by Amus- 
sat. It is performed by making an incision through the vul- 
var surface, using chiefly the fingers in the division of the 

soft parts, and proceed- 
ing step by step with 
tearing and dissecting 
combined. The finger 
of the operator or of an 
assistant should be kept 
in the rectum and the 
sound in the bladder. 
These organs can be thus 
readily recognized and 
their injury avoided. 
When a depth of from 
six to eight centimeters 
has been reached, or the 
peritoneum opened, the 
second step of the opera- 
tion should be performed, 
which is the investment 
of the funnel thus estab- 
lished with integument 
to prevent cicatricial con- 
traction. The skin and 
mucous membrane of the 
adjacent parts may be 
employed for this pur- 
pose. When the labia 
minora exist, they may 
be split and utilized for 
the lining of the anterior 
portion of the canal, while 
flaps may be taken from 
the vulva and inner side of 
the thighs to line the pos- 
terior walh (Figs. i6o and i6i.) After the sutures are applied the 
cavity is packed with iodoform gauze, and the packing is retained 
or renewed until cicatrization is complete, when the canal may 
subsequently be kept open by a glass plug. (Fig. 162.) In some 
cases attempts have been made to establish cicatrization over a 
glass plug in the newly created canal, without any attempt to 
line it with mucous membrane. Such a canal, how^ever, is ex- 




Fi 



161. — Flaps outlined in Fig. i6o Sutured 
in Place, and Denuded Stufaces which 
Have Furnished Flaps to line Posterior 
Wall. 



MALFORMATIONS. 



235 



ceedingly difficult to keep open, because it is liable to contrac- 
tion even though an obturator is constantly worn. The lining 
of such a canal has been accomplished by following the opera- 
tion by one upon another patient for redundant vagina, and 
utilizing the vaginal tissue removed to form a lining membrane 
for the newly created vagina. The tissue should be sutured 
over a glass plug (Fig. 162), or, preferably, over the end of a 
slightly distended bivalve speculum, which is introduced into the 
canal with the prepared hood of membrane, and as the speculum 
is withdrawn, some iodoform gauze is lightly packed through it, 
keeping the membrane in place. During the preparation of the 
vaginal lining the cavity should be packed with gauze, and the 
packing introduced with the hood should be removed at the end 
of a week. If the tissues by this time have united, it should be 
irrigated, removing any tissue which has not retained its vitality. 

In the patient represented by Figs. 160 and 161, after forming 
the wall of the anterior portion by splitting the labia minora, 
I transplanted a flap from the posterior part of each thigh, 
which fortunately became 
attached, and a very 
satisfactory vagina was 
formed. 

In making the dissec- 
tion for the vagina, no 
hesitancy should exist in 
opening through the peri- 
toneum. By making such 

an opening the presence and size of a rudimentary uterus are 
more readily determined and the latter organ affords a safe 
point for the fixation of the flaps to line the constructed vagina. 
I have no question that the employment of a portion of the sig- 
moid or ileum, as advocated by Baldwin, of Ohio, will prove the 
most efficient vagina. Such a procedure requires necessarily 
an abdominal incision, as the culdesac of the bowel must be 
restored by the anastomosis, throwing out the loop utilized for 
the vagina. 

306. Unilateral vagina is due to arrest of development in 
one of the ducts of Miiller, the other forming the vagina. Such 
a condition may be suspected when the canal is extremely narrow. 
In cases of double vagina there may be incomplete development 
of one of the ducts. 

307. Double Vagina (Fig. 163). — In this condition the 
septum divides the entire vagina, when the uterus is also double 
or divided. Occasionally, the septum in the uterus does not ex- 
tend through the external os, while that of the vagina terminates 
below it. The hymen may have two openings, simulating double 




Sims' Glass Dilator. 



236 



GYNECOLOGY. 




vagina. Coition generally occurs through the larger of the two 
conduits ; occasionally it takes place in either one. When the 
partition of the vagina is partial, the superior portion of the 
septum will be lacking. When the uterus is double, the upper 
portion of the vagina is often found to contain the septum, while 
fusion has been complete below. The septum is usually thick 
and fleshy, resembling the rectovaginal partition, or it may be 

very thin, and even 
perforated in places. 
Partition of the vagina 
is not incompatible 
with normal labor. 
Dunning has reported 
cases in which the two 
vaginae were separated 
by a septum that be- 
gan just above the 
vulva and extended to 
the interval between 
the two small cervices. 
The separation of the 
uterus into two parts 
was demonstrated by 
the use of the sound. 
Pregnancy occurred 
upon the right side, 
and as the uterus en- 
larged, the septum dis- 
appeared. During 
labor the vaginal por- 
tion was torn from top 
to bottom and only 
the lower portion per- 
sisted. An incomplete 
septum may form an 
obstacle to the passage 
of the child's head. 
When it does so, it 
should be incised. In one patient under my observation there 
had been a vaginal septum, which was destroyed during a 
previous labor, and there remained a bridle extending from the 
anterior wall of the vagina back to the posterior commissure, 
which hung below the vulva. Twice have I cut through the 
septum the entire length of the vagina, and sutured the surfaces 
on each wall, so that a single canal was formed. This course I 





■^*^ 



Fig. 163. — Double Ya.gma.— (Photograph taken 
from patient of Dr. J. M. Fisher.) 



MALFORMATIONS. 



237 




considered wise, as it decreases the discomfort during coition and 
removes a cause of dystocia in the event of pregnancy. 

308. Atresia of the genital canal is either congenital or 
acquired. The latter will be discussed farther on in these 
pages. Congenital atresia may affect any portion of the canal, 
but is more likely to occur within the vagina or near its orifice 
at the junction of the vagina and vestibular canal. Next in 
frequency is the atresia of the internal or external orifices of 
the cervical canal, although the congenital closure of these 
orifices is comparatively not nearly so frequent as is the ac- 
quired. Vulvar atresia is not un- 
common. It is produced by im- 
perforation of the hymen or ag- 
glutination of the labia minora 
or majora. In the latter there is 
usually an orifice in front through 
which the urine and menstrual flow 
can escape. Such conditions are 
often unrecognized until after the 
establishment of puberty, when the 
occurrence of periodic distress in 
the pelvis, colic-like pains, sensa- 
tion of weakness, bearing dow^n, 
and irritability of temper indicate 
an effort to establish the menstrual 
flow. The continuance without 
discharge, and later the develop- 
ment of a tumor in the median 
line, should awaken the suspicion 
of the attendant to the possibility 
of obstruction to the menstrual dis- 
charge and of its accumulation 
within the genital canal. The mere 
inspection of the parts discloses the 
imperf oration of the hymen. (Fig. 

164.) A tumor will protrude from the vulva ; there is difficulty or 
abnormal frequency in micturition, more or less obstruction in 
evacuating the bowels is experienced, and a smooth, purplish sur- 
face is seen at the vulvar orifice. If the obstruction is situated in 
the vaginal canal, the vulvar protrusion will not be so marked. 
The introduction of the finger into the canal, however, dis- 
closes the accumulation. It is more definitely determined by 
the finger in the rectum, when the globular tumor encroaching 
upon that organ is recognized. Pressure over the abdomen 
causes a sensation of elasticity or indistinct fluctuation. When 
the vagina is absent, the accumulation forms in the upper part. 



^ 



Fig. 164. — Imperforate Hymen. 



238 



GYNECOLOGY. 



of the vaginal canal or within the uterine cavity. An accumu- 
lation in the vagina is known as a hematocolpos ; in the uterus, 
as a hematometra ; in the Fallopian tube, as a hematosalpinx; 
in both uterus and vagina, as a hematocolpometra ; and when the 
distention also involves the tube, it becomes a hematocolpo- 
metrasalpinx. 

The symptoms are : absent menstruation, although the patient 
experiences each month discomfort, a sense of fulness or engorge- 
ment in the pelvis, with the usual nervous manifestations which 
awaken the anticipation that menstruation is about to make its 
appearance. A symmetrical enlargement of the lower abdomen 
appears, which from its contour has been mistaken .by the care- 
less observer for preg- 
nancy. The history of 
the case, with a careful 
physical examination 
of the patient, should 
establish the diagnosis. 
When the obstruction 
occurs at the internal 
OS with a normal cer- 
vix and roomy vagina, 
the diagnosis becomes 
more difficult. The 
mere fact that a girl 
has never menstruated 
does not exclude the 
possibility of preg- 
nancy. In the latter 
will be found mam- 
mary changes, an en- 
larged and softened 
cervix, increased va- 
ginal secretion, swell- 
ing, and a dusky appearance of the vagina and vulva. In the 
accumulation of blood these symptoms are absent and the cervix 
remains small, rather firm, and hard. As the accumulatin 
increases the cervix becomes softened, the uterus thinner, form- 
ing a thin- walled sac which affords distinct fluctuation. 

Treatment. — Operators were formerly very much averse to 
evacuating the fluid of such a collection. The fluid is thick, 
chocolate colored, and quite slimy, due, of course, to the 
retention of the blood and mucous secretions of the canal. 
It formerly was advised that a small pinhole orifice should 
be made through the opening in the hymen, to allow the dis- 
charge to continue slowly for several days. Such a procedure 





' '^W'^^'^^V^KKKK'^' '% 



-Hematocolpos. 



MALFORMATIONS. 



239 



almost surely resulted in infection of the material and produced 
an inflammatory condition of the genital canal which not in- 
frequently caused the death of the patient. The enormous dis- 
tention of the tissues renders them extremely anemic, and the 
removal of the pressure naturally permits an engorgement, 
which can readily result in inflammation. The most satisfactory 
method of treatment, however, consists in a free incision to 
evacuate the contents of the cavity ; remove the stringy mucus 
with the finger, and then thoroughly irrigate with a weak 
antiseptic solution, such as a two per cent, sodium bicar- 
bonate, three per cent, sodium chlorid, bichlorid of mercury 
(1:4000), or formalin (1:1500). A large quantity of the solu- 
tion should be em- 
ployed ; the irrigation 
to be followed, when 
of the two latter so- 
lutions, by a douche 
of normal salt solu- 
tion. Finally, when 
the quantity of fluid 
evacuated is large, 
the cavity should be 
lightly packed with 
iodoform gauze to af- 
ford moderate pres- 
sure upon the sur- 
face, to prevent en- 
gorgement, and to 
give the structures 
something upon 
which to contract. 
When the accumula- 
tion occurs above an 

obliterated or absent vagina, a trocar can be employed to reach 
the fluid, guided through the intervening structures with a finger 
in the rectum. The opening made by the trocar is then enlarged 
to permit a free evacuation, and the treatment already advised 
should be employed. When the accumulation occurs in the 
uterus from obliteration of the external os, it will often be diffi- 
cult to . determine the site of the latter. The cervix should be 
exposed, and if we can not determine the situation of the former 
OS, a puncture should be made with the trocar, which opening 
should subsequently be enlarged in order to permit the evacua- 
tion of the uterine contents. The cavity is then irrigated and 
packed with gauze. If the obliteration has developed at the 
internal os, the remaining cervical canal affords a passage 




Fig:. 166. — Hematometra. 



240 GYNECOLOGY. 

through which the puncture can be safely made. The canal 
having been dilated and the cavity thoroughly irrigated, the 
latter should be lightly packed with gauze. 

In all cases in which the obstruction is found in the uterine or 
cervical wall, measures should be instituted to secure subse- 
quently a patulous canal, otherwise the obstruction will be re- 
produced. The better plan of procedure will be to suture the 
internal and external surfaces of the uterus. 

The one element of danger in these operations occurs when 
the Fallopian tube is distended with an accumulation and is 
fixed by extensive adhesions. The dragging upon the thin 
tube which occurs from the contraction of the empty uterus 




i 



Fig. 167. — Hematocolpometra. 

may cause its rupture and the escape of its contents into the 
peritoneal cavity. Extreme care should be exercised in a 
hematosalpinx not to make much pressure upon the abdominal 
surface while the sac is being emptied. Whenever the sac has 
disappeared with insufficient discharge from the uterus, or when 
it has disappeared before the opening into the collection has 
occurred, an immediate abdominal incision should be made to 
cleanse the peritoneum and remove the offending sac. 

309. Lateral Atresia. — Atresia may take place in one-half of a 
divided vagina or uterus. When it occurs in a portion of the 
vagina, a lateral tumor will project into the vaginal canal, which 
will be so elastic and obscure as to render doubtful the fact 
whether it is a pelvic cyst or a lateral hematocolpos. Such 



I 



MALFORMATIONS. , 241 

cases are less dangerous than atresia of the entire half of 
the vagina, as the accumulation will probably rupture into 
and discharge through the existing vagina. The opening, how- 
ever, will be high, permitting serious symptoms from infection 
and the development of a pyocolpos. It is generally advised 
to make a free incision and pack such a cavity with iodoform 
gauze, but I much prefer to excise a large section of the wall 
and unite the mucous surfaces of its cut edges so that the 
two chambers become one. When, the atresia has occurred in 
one half of the uterus, the diagnosis is difficult. It is not always 
situated to one side of the developed horn, but may curve about 
it. The accumulation may then be accessible through the vagina, 
or may be exceedingly difficult to reach. When accessible, it 
should be opened through the vagina. When inaccessible 
below, the tumor should be removed by an abdominal incision, 
as for pyosalpinx. 

310. Absence of the vulva is generalH^ associated with a 
similar condition of the vagina and uterus, although this de- 
fect may exist with a normal development of the other genital 
organs. It then probably results from coalescence of the 
labia majora. The latter are generally absent in exstrophy of 
the bladder, and may also be found so in other malformations. 
The nymphas can be absent and the clitoris so imperfectly 
developed that the site of the vulva presents a mere slit or 
flattened surface, upon which the urethral orifice opens. 

311. Infantile vulva is found in weak, sickly women, who 
have suffered from prolonged ill health prior to puberty, and 
is generally associated with an imperfect development of the 
uterus and tubes. The mons veneris and labia majora will be 
bereft of, or sparsely covered with, hair. 

312. Defects in Nymphae. — Absence of the nymphse is in- 
frequent, and is accompanied by incomplete development of 
the clitoris. More frequently they are thin, flabby, elongated, 
and pointed. Occasionally they are perforated by small open- 
ings. Hypertrophy of the nymphse is much more frequent. 
The nymphae project beyond the labia majora; in the Bush- 
women of Africa they form large folds, which reach nearly to 
the knees, and are known as the Hottentot apron. 

313. Defects of the Clitoris. — The clitoris may be so enor- 
mously developed as to cause the sex of the individual to be 
questioned. In exstrophy of the bladder and absence of the 
symphysis it may be bifid or rudimentary. It is rarely absent. 
Frequently, from congenital conditions or from neglect of 
cleanliness, the smegma is retained beneath the prepuce, pro- 
ducing such irritation and adhesions that the glans clitoris is 
compressed and prevented from attaining its normal size. The 

16 



242 



GYNECOLOGY. 




\ 



adhesions become so firm as to render tlieir separation difficult. 
The existence of adhesions and the retention of smegma are 
capable of producing quite as marked nervous phenomena as the 
analogous condition in the male, some of which are: irritable 
bladder, nervous disturbances, masturbation, absence of sensa- 
tion, and convulsions. The occurrence of such symptoms should 
direct attention to the clitoris as a possible cause. 

Treatment. — When the clitoris is so large as to interfere with 

coition, a portion of it may 
haA'e to be removed, but 
the operative procedure 
should, if possible, be so 
designed as to retain the 
glans as the seat of sensa- 
tion. If the glans is covered 
by an adherent prepuce, 
it should be thoroughly 
exposed by pushing back 
the prepuce. The adhe- 
sions can readity be broken 
up with a probe or a 
grooved director. When 
the prepuce is so long as 
to form a hood and com- 
pletely envelop the glans, 
it should be retracted by 
removing an elliptic piece 
of integument about half 
an inch above the clitoris, 
with the long diameter of 
the ellipse parallel to the 
cleft of the vulva. This 
denuded portion should 
be closed by sutures intro- 
duced in its long axis. 
The length of the denuda- 
tion necessary depends 
upon the projection of the 
prepuce. The prepuce may be dissected away and the cut edges 
sutured so that the glans subsequently remains exposed. A better 
procedure is to remove the margin of the prepuce around the 
glans. The cut edges should then be united with catgut sutures. 
314. Defects of the Hymen. — The hymen is composed of 
tissue analogous to the corpus spongiosum in the male. It 
partly closes the vaginal orifice, and has upon its superior surface 
the foldings of the mucous surface of the vagina. It is generally 



^ 



.;^ 






Fis:. 1 68. — Enlaro-ed Clitoris. 



MALFORMATIONS. _ 243 

crescentic (Fig. 112), with the concave margin anterior. It 
can present an annular opening (Fig. 113); two openings, sepa- 
rated by a septum (Fig. 116); or a number of openings (Fig. 
117) — the cribriform. It sometimes resembles in appearance 
the infantile form, when it is infundibuliform (Fig. 115), or its 
edges may be dentated (Fig. 114) or serrated. Its normal 
situation is just within the vulva, where it is exposed by sepa- 
ration of the labia. In the colored race its situation is higher. 
Its opening in the marriageable woman will easily admit the 
tip of the finger. Atresia has been described. (Section 308.) 
Supernumerary hymen have been reported, but these are prob- 
ably congenital bridles in the vagina. A congenital absence 
of the hymen must be questioned. The hymen is generally a 
thin membrane, which ruptiu'es during the first coition (Fig. 118) 
and sloughs away after confinement, leaving as remnants the 
carunculae myrtiformes. The laceration may be central pos- 
terior, triangular, or stellate. After a single coition the torn 
surfaces may unite. I have seen two patients in whom the 
hymen was so firm as to form an actual barrier to coition, re- 
quiring incision to render the act possible. Cases are reported 
where it did not rupture during labor, or offered such an ob- 
stacle to delivery as to require incision. Its laceration is not 
usually attended with bleeding, but occasionally it is, however, 
followed by severe, and even dangerous, hemorrhage. 

Incision is made with bistoury or scissors, while the labia 
are widely separated. Two posterior lateral incisions are 
preferable to a single posterior. Hemorrhage, if severe, should 
be controlled by a vaginal tampon, or, preferably, by a suture. 

315. Hermaphroditism is a condition in AA^hich there is a real 
or apparent union of the two sexes in the same individual. 
It is doubtful whether the organs of both sexes exist complete 
in any one individual, although there are numerous instances in 
which the penis has been found well developed, with a testicle 
upon one side, while within were found a uterus and an ovary 
upon the other side of the body. The case represented in figure 
169 presents characteristics of the two sexes, but, like many 
other such cases, requires a microscopic examination to demon- 
strate the presence of both ovaries and testicles in the same 
individual. 

Pseudohermaphroditism is a condition in which there is 
such an apparent union of the sexual organs of the two sexes, 
or such a malformation, or defective development of the male 
organs or excessive development of those of the female, as to 
render the determination of the sex of the individual during 
life difficult, if not almost impossible. Pseudohermaphroditism 
is divided into masculine and feminine, according to the pres- 



244 



GYNECOLOGY. 



ence of testicles or ovaries. The females resembling men 
form a class known as the gynandria, while the man resembling 
the female is classed as an androgynus. 




Fig. 169. — Apparent Hermaphroditism. — {'^American Journal of Obstetrics.") 

316. Gynandria. — The external organs of the female re- 
semble those of the male. The clitoris is large, with possible 
fusion of the labia majora, not infrequently of the labia minora. 




Fig. 170. — External Genital Organs of Madame Le Fort. — (Auvard.) 



simulating the scrotum and concealing the vulvar opening. 
This resemblance is still miore striking when there is associated 
an ovarian hernia into the labium ma jus. The internal organs 



MALFORMATIONS. 



245 



may be irregularly developed. The hypertrophy of the cHtoris 
does not necessarily change its form, and may arise in women 
who are addicted to masturbation. The labial fusion may 
be so firm as to require incision. 

An example of this class is ]\Iadeline Le Fort (Auvard) 
(Fig. 170), who was declared to be a female by Beclard when 
she was six years of age. The clitoris was very large; a groove 
upon the under surface led to a depressed urethra in the cleft 
of the vulva. The vagina w^as replaced by a small conduit, 
from eight to ten centimeters long, bordering upon a well- 




Fig. 171. — Outline of Internal Organs of Madame Le Fort. — (Auvard.) 



formed uterus. (Fig. 171.) ]\Ienstruation occurred at the eighth 
year, and escaped from an orifice situated at the root of the 
clitoris. Her general appearance was strongly masculine, 
and she was sexually indifferent. 

317. Androgyna. — ^This class predominates, and its individuals 
are frequently monorchid or crypt orchid males, presenting ex- 
ternal characteristics of the female, such as enlarged breasts. 
The penis may be perfect, but the nondescent of the testicles 
and a median depression in the scrotum resembling the labia 
majora will give a distinctly feminine aspect. Arrested devel- 



246 



GYNECOLOGY. 



opment of the penis, hypospadias, and fissure of the scrotum 
greatly increase the resemblance. (Fig. 172.) Such persons 
are generally dressed, reared, and educated as girls, and have 
been married without being aware of their true sex. 

The determination of sex is of great importance. It re- 
quires careful consideration of the size, shape, and general 
configuration of the body. The testicle may be small, and 
be retained within the abdominal cavity. The seminal secre- 
tion is generally sterile. The breasts resemble the feminine, 
as do also the buttocks and thighs. The larynx is not promi- 
nent and the beard is scanty or absent. The rectal touch, 
with the catheter in the bladder, may fail to reveal either 
uterus or prostate. The mental condition is 
generally feeble or poorly balanced. When 
careful examination fails to render the sex 
certain, the individual should be classed as 
a male. Independent of increased freedom 
and larger opportunities for acquiring a live- 
lihood, the imperfect male is less likely to 
enter upon the marriage relation. When 
the sex of the individual is in doubt no 
operation for correction of the condition 
should be done, unless preceded by an ab- 
dominal section to ascertain the character of 
the internal genital organs. 

318. Atresia of the urethra and vagina has 
been noted, but a fetus with this condition 
is nonviable. 

319. Hypospadias is much more rare in 
the female than in the male. The vestibule 
is absent and the orifice of the urethra is 
not visible to inspection. Generally, the 
apparent hypospadias is really a persistence 

of the urogenital sinus. The urethra can be wholly absent, and 
the bladder ma}^ present a crescentic opening into the vagina. 
It is often associated with prolapse of the bladder-wall, and incon- 
tinence is usually present. 

320. Epispadias is still more rare. It presents four varieties: 
(i) The corpus spongiosum is divided, and the urinary sinus 
is situated in the posterior surface of the clitoris; (2) added 
to the former condition there is a partial defect of the anterior 
urethral wall; (3) the anterior wall of the urethra is entirely 
absent, the clitoris is bifid, and the labium minus is attached 
on either side to a portion of the glans clitoris, while the pubic 
symphysis may also be defective; (4) exstrophy of the bladder, 
in which the anterior wall of the abdomen, with that of the 




Fig. 172 . — Androgy 
na. — (Pozzi.) 



I 



MALFORMATIONS. 



247 



bladder, is absent and the posterior vesical wall protrudes. 
The ureters open upon the surface, and the parts are constantly 
soiled with urine. 

The first form of epispadias is very rare, the last most fre- 
quent. While vesical ectopia is prone to result in disease and 




Fig. 173. — Imperforate Anus. Communication between Rectum and Vagina^ 




Fig. 174. — Congenital Defect of Vagina. Communication with the Rectum. 



obstruction of the ureters, which lead to hydronephrosis and 
early death, nevertheless histories of patients have been re- 
ported who have reached old age. The occurrence of epi- 
spadias and associated incontinence is not inimical to the oc- 



248 



GYNECOLOGY. 



currence of conception, and cases of pregnancy at full term 
are recorded. 

Treatment. — The urethra may be established by denuding 
and suturing the surfaces, but failure to secure a good result 
is frequent. Ectopia of the bladder is difficult of correction. 




Fig. 175. — Congenital Absence of the Urethra. Communication of Bladder 

with the Vagina. 




Fig. 176. — Communication of Rectum and Bladder with the Vagina. 



It is preferable not to attempt an operation during infancy, 
owing to the friability of the tissues and the probability of 
sutures cutting through. Transplantation of the ureters into 
the rectum probably affords the most satisfactory solution 
of the problem. 

321. Duplication of the bladder has been found associated 
with a similar condition of the genitalia. 



MALFORMATIONS. 



249 



322. Open Urachus. — Permeability of the urachus and dis- 
charge of urine from the umbihcus are a result of congenital 
closure of the urethra, but sometimes occur independently. It 
is much more frequent in boys than in girls. 

323. Irregular Exit of Ureter. — Opening of the ureter into 
the vagina has been described, but these are probably cases 
in which the supposed vagina is really a rudimentary bladder. 
I had an opportunity to examine a young woman in whom the 
bladder was rudimentary and the vagina formed a receptacle in 
which urine accumulated and prevented incontinence becoming 
complete. Baum describes an accessory ureter which opened at 
the side of the urethra. He operated by making an incision 
above the symphysis, cutting through the bladder upon the 




Fig. 177. — Suprapubic Opening of Vagina and Urethra. 



ureter, which he divided, tying the distal end, while the other 
was brought into the bladder. The procedure overcame the 
incontinence. 

324. Abnormal Communications. — Errors in development 
may produce imperforation of one of the canals which per- 
forate the pelvic fascia or result in the union of tAvo or three 
of them. In any case the cause is analogous: i. e., failure to 
accomplish the union between the superficial and deep organs. 
Imperforations of the anus and urethra are vital, calling for 
prompt attention of the surgeon. Imperforation of the vagina 
has been considered. (Section 305.) The communications may 
be: 

I. Rectovaginal. (Fig. 173.) The vagina and urethra are 
normally developed. The anus is imperforate and, therefore, 
the fecal material is discharged by a rectovaginal opening through 
the vaccina. 



250 • GYNECOLOGY. 

2. Vaginorectal. (Fig. 174.) The rectum and urethra are 
normally developed, excepting the opening into the former 
from the incomplete vagina. 

3. Vesicovaginal. (Fig. 175.) The rectum and vagina are 
normal in appearance, but the urine escapes through the latter, 
the urethra being absent. 

4. Rectovagino vesical. (Fig. 176.) The rectum and bladder 
both communicate with the vagina. The urethra is generally 
absent. The anus may or may not be perforate. 

5. Suprapubic opening of vagina and urethra. (Fig. 177.) 
This condition is extremely rare. 



TRAUMATISMS. 

325. Injuries of the genital organs of sufficient gravity to 
produce temporary or permanent structural changes, to in- 
fluence the subsequent health and comfort of the patient, are, 
for the most part, limited to lesions of the vulva, vagina, and 
cervix. 

The causes productive of such conditions may usually be 
assigned to one of three general classes, viz. : 

1. External violence. 

2. Coition. 

3. Parturition. 

326. External Violence. — The cases of injury from external 
violence are comparatively infrequent. 

They occur in a variety of ways. 

A woman standing upon a chair or step-ladder falls astride 
the back, or upon the post or round of the chair. 

Bovee reports the case-history of a young girl who fell from 
her bicycle upon the lamp bracket and sustained a complete 
laceration of the perineum. Lacerations may be produced 
by sliding down bannisters and striking against the newel 
post, by sliding from a haystack or haymow, falling upon the 
handle or prong of a fork or upon a hay-knife. Howe men- 
tions a young woman who thus slid upon the handle of a fork, 
which entered the vagina and penetrated the abdominal cavity 
twenty-two inches, and from which she ultimately recovered. 
Curran cites the case of a patient in whom the horn of a goat 
entered the anus and tore through the vagina. Girls have 
been impaled upon barrel staves, fence palings, or the sharp 
stump of a sapling. A chamber or slop- jar breaking under 
the patient has been the cause of injury. The fracture of a 
glass-ball pessary in the efforts at its removal has produced 
vaginal laceration and even fistula. Royster reports two cases 



TRAUMATISMS. - 251 

of complete laceration of the perineum in young girls, which 
were caused by the finger of the obstetrician while they were 
yet within the body of the mother. The injury may be a free 
incision, a ragged laceration, or a severe contusion. The in- 
cision may be produced by striking upon a blunt object, the 
sharp edge of the rami cutting through the overlying tissues. 
Large vessels may be ruptured without the skin being broken, 
when a severe hemorrhage will occur into the tissues. In 
the former case the hemorrhage w411 be open; in the latter, 
concealed. 

Treatment. — The injury of vessels and the resulting hemor- 
rhage into the tissues are called pudendal hemorrhage (see Vulvar 
Hematoma). This may demand evacuation, and the resort 
to measures for the control of the bleeding vessels. 

Severe hemorrhage following an injury should demand 
an inspection of the injured part and the resort to measures 
for its control. Where a good-sized vessel is bleeding, the 
wound, if necessary, should be enlarged and the vessel ligated. 
Frequently the hemorrhage can be controlled by the sutures 
which are employed to close the wound. General oozing from 
a ragged opening is often best controlled by gauze pressure. 
The w^ound must be carefully cleansed and maintained in an 
aseptic condition. 

327. Coition, as is well known, causes a rupture of the mem- 
brane — the hymen — which guards the vaginal opening. Lacera- 
tion of this structure is usually central and posterior. It may, 
however, be bilateral. Occasionally, as has been seen, the 
hymen is so firm as to resist all attempts at coitus, and, there- 
fore, will require incision before the act can be accomplished. 

The entire vaginal canal is more or less dilated by the repe- 
tition of the sexual act, as is evidenced by the enlarged and 
roomy canal which distinguishes the nulliparous from the 
virgin vagina. Severe lacerations of the vulva and vagina the 
result of sexual intercourse are rare, except when produced 
by rape of young girls. Instances are reported, however, in 
which injuries of gravity have been produced, as the tearing 
off of the hymen, the perforation of the posterior vaginal wall, 
the rupture of the perineum, the formation of rectovaginal 
fistula, and perforation of the posterior vaginal fornix. Such 
injuries are more likely to occur in those who come to the first 
coitus late in life, or in whom there have been premature atrophic 
changes. Skrobanski, however, cites a young peasant, aged 
twenty-two years, in whom the first coitus caused a rupture 
of the perineum, two centimeters in depth, but without enter- 
ing the rectum. R. i\brahams reports the history of a woman,. 



252 



GYNECOLOGY. 



twenty-six years old, in whom a rectoperineal fistula was 
produced which permitted the introduction of two fingers. 

Occasionally the first coitus is followed by a hemorrhage 
so active as to endanger the life of the woman. The bleeding 
is best controlled by the introduction of a suture to include 
the spurting- vessel. 

Treatment. — Injuries resulting from the sexual act are 
rarely of sufficient importance to demand surgical interference. 




Fig. 178. — Knives for Denudation. 




Fig. 179. — Curved Scissors. 




Fig. 180. — Retractor, 



If severe, the treatment will depend upon the character and 
extent of the injury. An extensive laceration should be sutured. 
The sexual act should be discontinued until the injured parts 
have fully recovered, and it then should be practised with the 
utmost gentleness and care. 

328. Parturition. — Maternity is not without its penalty. 
The great majority of the injuries to which the genital organs 
are subject occur during or as the result of labor. The in- 
juries are due to faulty anatomic conditions, as distorted pelves, 



TRAUMATISMS. 



253 



rigid, unyielding muscles, inflamed and undilatable cervices, 
abnormal positions of the fetus, disproportion between its size 
and that of the pelvis, violent uterine contractions, long-delayed 
and feeble contractions, and premature or too long postponed 
instrumental or manual interference. 

The long-continued pressure of the fetal head impacted 
in the pelvis is probably even more disastrous than the pre- 
mature delivery by the application of forceps. Indeed, vesico- 




Fig. 182.— Needle-holder. 




Fig. 183.— Needles. 




Fig. 184. — Needle with Loop for Suture. 



vaginal fistulae, which were of frequent occurrence prior to 
the educated use of the forceps, now rarely come under ob- 
servation. The injuries are of great variety, and affect the 
uterus, — both body and cervix, — the vagina, the vulvar out- 
let, and particularly the perineum. 

329. Injuries of the body of the uterus may occur in the 
form of lacerations of the anterior or posterior wall, in a vertical 
or transverse direction, and may be slight or sufficiently large 



254 GYNECOLOGY. 

to permit the escape of the fetus and placenta. After an abor- 
tion, the softened uterine wall is occasionally perforated by 
the curet or placental forceps or both, and through such a per- 
foration loops of intestine have entered the uterine cavity, 
been drawn through the os, and subjected to serious injury. 
Injuries of this structure are not confined to parturition alone, 
but the walls of the inflamed or flexed nonpuerperal organ are 
frequently perforated by the use of the sound or bougie. In 
removal of fibroid growths, the weakened wall can be ruptured 
and the tumor projected through it, or the fundus uteri can 
become inverted and be incised during the removal of the growth. 

Treatment. — For the proper course of treatment in rupture 
of the uterus during labor the student is referred to one of the 
text-books on obstetrics. Perforation of the uterus in the 
effort to evacuate decomposing placenta or membrane follow- 
ing an abortion should demand careful subsequent observation. 
In such cases the danger of perforation is so great that the 
retained fragments should be removed, if possible, by the finger, 
and placental forceps should only be used with the finger as 
a guide. Evidence of perforation as presented by bringing 
a coil of intestine to the os should require careful replacement 
of the knuckle of the intestine and a certain determination 
that it has been pushed entirely through the uterine wound, 
after which the uterus should be packed with iodoform gauze. 

Any appearance of shock, disturbance of temperature, or 
continued and severe irritation of the stomach should be recog- 
nized as an urgent indication for abdominal section. Perfora- 
tion of the uterine wall by sound or bougie, unless associated 
with infection, has but little significance. Care should be 
exercised, however, not to irrigate with irritating fluids, and 
drainage of the uterus should be secured by gauze. The lacera- 
tion of the uterus during removal of fibroid growths should be 
considered an indication for immediate suturing of the wound 
through an abdominal section. 

330. Injuries of the cervix uteri are described under the 
term laceration. Laceration of the cervix is the most frequent 
lesion of labor. It is exceedingly rare for a w^oman to undergo 
her first parturition without tearing of one or both sides of the 
cervix. The tear may vary from a slight fissure, which com- 
pletely disappears during convalescence, to an extensive lacera- 
tion, extending to or into the vaginal fornices. 

Lacerations of the cervix are unilateral, bilateral, stellate, 
and through the anterior or' posterior lip. The bilateral is 
the most frequent. The unilateral is more frequently found 
upon the left side, owing to the greater preponderance of the 
left occipito-anterior position. Lacerations can occur into the 



TRAUMATISMS. 255 

cellular tissue laterally, or into the bladder in front, and in the 
latter cause a vesico-uterine fistula. (See Section 353.) The 
cicatrization of a lateral tear may produce a band or bridle which 
tilts the fundus uteri to the opposite side. 

331. Symptoms. — Laceration of the cervix presents no special 
or specific indications of its existence. The symptoms are 
those produced by the complicating conditions. The lesion 
causes subinvolution and a consequent increased weight. A 
bearing-down sensation, discomfort in standing or walking, 
and pain in the sacrum and iliac regions are common. The 
lower level maintained by the organ and the traction of the 
vaginal wall upon its lips lead to separation of the latter, 
e version of the cervical mucous membrane, thickening of the 
tissue from its exposure, and fixation of the everted lips. Ir- 
regular or excessive menstruation, or metrorrhagia, is not 





Fig. 185, — Slight Fissure of Cervix. Fig. i86. — Extensive Laceration of 

Cervix. — (Munde.) 

infrequent. Bleeding is excited by locomotion, coition, or 
sexual excitement. The endometritis causes a profuse leu- 
korrhea, which constitutes a double drain. The cicatricial 
bands and the everted lips not only permit a depression of the 
uterus in the pelvis, but produce either lateral version or retro- 
version, according to the unilateral or bilateral character of 
the lesion. With cicatrization of the lacerated surfaces, not 
infrequently the scar tissue in the angles of laceration causes 
pressure upon the nerves, producing profound neurotic or 
reflex phenomena. Not infrequently the presence of neu- 
rasthenia may be created by pressure of the cicatricial tissue 
upon the nerve filaments. Pressure with the finger against 
•such indurated tissue aggravates the reflex phenomena. 

332. Diagnosis. — A laceration of the cervix is readily recog- 
nized by the finger, but its apparent presence must not be 



256 



GYNECOLOGY 



accepted as proof positive of previous pregnancy, for a congenital 
fissure can exist which will permit as marked an eversion of the 
lips as would be produced by a deep bilateral tear. The finger 
will disclose the condition of the lesion, the extent of the cicatri- 





Fig. 187. — Bilateral Laceration of 
Cervix. — (Munde.) 



Fi: 



[. 1 88. — Slight Stellate Laceration 
of Cervix. — {Munde.) 



zation, the eversion of its lips, the presence of erosion (dis- 
closed by its soft, velvety feel), or the existence of eversion of 
the cervical mucous membrane. Inflammation and obstruc- 
tion of the glands of Naboth will be revealed by small, shot-like 
masses studding the cervix. As the finger is passed upward the 





Fig. 189. — Extensive Stellate Lacera- 
tion of Cervix. — (Munde.) 



Fig. 190. — Laceration of Cervix with 
Hypertrophy and Eversion of 
Cervical Mucous Membrane. — 
(Munde.) 



lips will be found to spread out, like the top of a celery stalky 
but hard, dense, and fixed. 

The bivalve speculum, in drawing upon the anterior vaginal 
wall, aggravates the eversion. The tubular speculum flattens 
the surface, removes all trace of the fissure, and leads to its being 



TRAUMATISMS. 257 

mistaken for granular erosion. The Sims or some retraction 
speculum affords the best exposure. Seizing each lip with a 
tenaculum and drawing them together discloses the extent of 
the tear. (Fig. 192.) The surface of the tear is covered with 
exuberant granulations, which bleed upon the slighest touch 
(Fig. 190), and the profuse discharge renders the differentiation 
from epithelioma sometimes exceedingly difficult. The diagnosis 
may be established by the results of treatment. 

333. Treatment. — Immediate examination after labor to 
ascertain the extent of laceration is generally impracticable, be- 
cause the cervix is so drawn out and thinned that it is difficult 
to determine the lesion. The majority of small lacerations close 
spontaneously under the employment of ordinary antiseptic pre- 
cautions. The existence of severe arterial hemorrhage should 
require an examination to ascertain its source, and when found, 
is best controlled by suturing the lacerated surfaces. Not 
every laceration demands an operation, and if not done within 
a week, three months should pass before it is repaired. I quite 
agree with Dickinson that the period of choice for operation is 
five to seven days following the occurrence of the lesion, for at 
this time involution has taken place sufficient to permit the lesion 
to be disclosed, and operation at this stage favors normal involu- 
tion thereby, and lessens the danger of the occurrence of endome- 
tritis and other complications. Small fissures which are in- 
clined to close or have cicatrized do not require an operation. 
When the lesion is complicated with endometritis, the latter 
should be treated. Operation in slight cases is to be condemned, 
as it obstructs drainage and may cause the extension of disease 
to the tubes and pelvic peritoneum. Repair is indicated in 
deep laceration, in eversion with hypertrophy and cystic degen- 
eration of the mucous membrane, in cicatricial formation at the 
angles of the fissure producing reflex phenomena, and in sub- 
involution and endometritis. In addition to slight lacerations- 
and those which have cicatrized, surgical interference confined to 
this lesion is contraindicated in tubal or peri-uterine disease. 

334. Complications. — The presence of endometritis, associated 
with marked eversion and hypertrophy of the mucous mem- 
brane, requires treatment prior to the operation for laceration. 
The patient's diet should be regulated, constipation corrected, 
and appropriate measures instituted to relieve the accompany- 
ing anemia ; she should be permitted to take a vaginal douche of 
hot water containing an ounce of rock-salt to the quart twice 
daily. The cervix should be scarified or punctured, thus securing 
depletion. All obstructed Nabothian glands should be punc- 
tured and the gland cavity painted with Churchill's tincture of 
iodin, a combination of tincture of iodin and creasote (2: i), 

17 



258 . GYNECOLOGY. 

iodin crystals dissolved in 95 per cent, carbolic acid solution, 
silver nitrate (5j to f§j), zinc chlorid (3j to f 5 j), solution of 
argyrol, or pyroligneous acid. The superfluous material should 
be sponged away and a tampon of gauze and cotton applied be- 
neath the uterus. By raising the organ to a higher level the 
sensation of weight or heaviness is removed and the circulation 
is improved. 

The tampon may consist of plain sterilized gauze and cotton or 
medicated gauze (iodoform, carbolic or boric acid, or thymolized). 
Sublimated gauze should not be used, because it causes pruritus. 
The tampons may be medicated with preparations of glycerin, 

R. Alum ^j 

Acid, carbolic, ^iv 

Glycerin ,^ xij 

a fifty per cent, solution of boroglycerid, the official iodoform 
ointment, or a ten per cent, solution of ichthyol. In place of 
the glycerin the tampon may be medicated with an ointment, 
such as twenty-five per cent, of ichthyol in lanolin. The local 
treatment, followed by a tampon, should be applied twice a week, 




Fig. 191. — Blunt and Sharp Curets. 

and the latter removed at the end of forty-eight hours, to be 
followed by a vaginal douche of half a gallon of hot salt water 
(temperature from 110° to 120° F.) twice daily. The douches 
are preferably given with a fountain (gravity) syringe, while the 
patient is in a recumbent position on a bed-pan; although in 
those cases in which the cervix and the neighboring tissues con- 
tain a large amount of inflammatory exudate the bulb (David- 
son) syringe, by force of its current, exercises a salutary influence 
in promoting absorption. A profuse discharge of glairy mucus 
from the surface should be removed with a blunt curet. The 
curet presses the mucus-collections from the cervical glands and 
permits the application to come directly in contact with the 
diseased surface. The medicament may be applied by means 
of a cotton-wrapped probe, or be carried into the canal with 
a pipet. (Fig. 89.) Intracervical applications should not be 
made, however, unless the cervical canal is quite patulous, so 
that the fluid or increased serous discharge can readily escape. 
If the canal is obstructed by hypertrophied and everted mucous 
membrane, gauze packing (Section 90) or the use of a laminaria 



I 



TRAUMATISMS. 



259 



tent (Section 85) will render the application more effective and 
safe. Irregular bleeding or profuse leukorrhea should indicate 
the use of the sharp curet (Section 91), after dilatation (Section 
87). The uterus should be irrigated during or following curet- 
ment with a disinfectant solution, bichlorid, 1:3000; formalin, 
1 : 1000, a hot soda solution, 4 drams to 2 pints, or preferably 
with normal salt solution, and swabbed with a saturated solution 
of iodoform in ether. If for any reason there is much bleeding 
following the procedure, the uterine canal should be packed 
with iodoform gauze. 

335. Trachelorrhaphy (that is, neck-sewing), or hystero- 
trachelorrhaphy (that is, womb-neck sewing), is the operation 
devised by Emmet for the relief of laceration of the cervix. 
Patient, prepared (Section 182) and anesthetized (Section 190), 
is placed upon a table in the 
lithotomy position, with a 
perineal pad beneath her 
buttocks to carry the irrigat- 
ing fluid into a slop-jar at 
the end of the table. Each 
leg is held by an assistant 
or secured by a leg-holder. 
The following sterile instru- 
ments (Section 174) have 
been placed in a tray upon a 
table at the operator's right : 
a scalpel or bistoury ; curved 
scissors ; long, rat -toothed dis- 
secting forceps; two double 
tenacula; a retraction spec- 
ulum (Edebohls') ; six pres- 
sure forceps ; a needle-holder ; 

four strong needles, curved and bayonet-pointed, each threaded 
with a loop of silk to serve as a suture carrier. A smaller tray 
will contain the suture material. i\Iy preference for sutures is 
chromic catgut, which has the advantage that it does not have 
to be removed (Section 176). The nurse at the operator's 
left should have charge of the sponges. These should pref- 
erably be sterilized gauze, though absorbent cotton wet with sub- 
limate solution, I : 2000, can be employed. A fountain syringe, 
filled with hot normal salt solution or some disinfecting fluid, 
should be suspended, so that the field of operation can be sub- 
jected to constant irrigation. The final preparation of the patient 
(Section 182) completed, the cervix is exposed with a speculum, 
and each lip so seized with a double tenaculum as to turn in 
the everted edges when the lips are apposed. (Fig. 192.) The 




Fig. 192. — Edges of Laceration Turned 
by Tenaculum Hooked into Each Lip. 



260 



GYNECOLOGY. 



assistant upon the operator's left holds the anterior lip by the 
tenaculum and controls the irrigation tube; the one upon the 
right attends to the necessary sponging. The posterior lip is 
held by the weight of the tenaculum. With the knife the 
operator cuts through the cicatricial angle, and in a bilateral 





Fig. 193- 



-Denudation of Lacerated 
Cervix. 



'ig. 194- 



-Surfaces Denuded Ready 
for Union. 



laceration with scalpel and forceps denudes a corresponding 
surface upon each lip, first upon the left, then upon the right. 
The knife is preferred to the scissors, as the denudation can be 
made more evenly and with less bruising of tissue. The de- 
nudation is, of course, limited to one side in a unilateral tear. 
A strip of undenuded mucous membrane, one centimeter wide, 
should be left in each lip for the future cervical canal (Fig. 193), 





Fig. 195. — Sutures Introduced. 



Fig. 196. — Sutures Tied. 



and the precaution should be exercised not to encroach upon 
the vaginal surface of the cervix in the removal of the tissue. 
In deep lacerations the circular artery may be opened in the 
denudation. It should be seized with pressure forceps, and 
the first suture should be so introduced as to control it. 



TRAUMATISMS. 



261 



The sutures are placed by introducing the needle about 
three millimeters from the vaginal edge of the wound, bring- 
ing it out at its cervical margin, introducing it at a similar 
point in the other lip, and bringing it out in the vagina. Or- 
dinarily, three sutures will be sufficient upon each side. Occa- 
sionally the laceration will be so deep that the angle suture 







1^ 




W 




Fig. 197. — Double Flap Amputation 
of the Cervix. — (Auvard.) 



Fig. 198. — Sutures Introduced. 
(Atward.) 



can not be properly placed by passing the needle as we have 
just described. It is then preferably introduced from within 
outward, which can be done by carrying the ends of the suture, 
by means of the carrier, through first the posterior and then 
the anterior lip, or with two need- 
les threaded with carriers, each passed 
from within outward, the one ante- 
rior and the other posterior. One 
carrier is passed through the loop of 
the other and drawn out. The loop 
thus carried through serves to carry 
the suture. The sutures are tied, super- 
ficial sutures are introduced, if needed, 
and the vagina is thoroughly irrigated. 
If bleeding should continue, a suture 
should be introduced well above the 
denudation to control the bleeding 
vessel. Avoidance of subsequent hem.- 
orrhage is particularly desirable if a plastic operation is also to 
be performed upon the vaginal outlet. 

336. Amputation of the cervix is to be preferred when the 
cervix is much elongated and hypertrophied, when the mucous 
membrane has become extensively hypertrophied and everted, 
and when cellular proliferation justifies the suspicion of incipient 
malignant degeneration, although when the latter condition is 




ig. 199. 



-Wound Closed. 



262 



GYNECOLOGY. 



established , completehy sterectomy would be the better course to 
pursue. 

The amputation can be made by the double or single flap 
method for each lip. The instruments and preparations are 
similar to those given in the previous section (Section 335). 

Double Flap Operation. — The lips of the cervix are seized 
and separated by double tenacula; an incision is made in each 
angle to the point at which it is desired to make the amputation. 
A wedge-shaped piece is removed from each lip, forming cer- 
vical and vaginal flaps. Two sutures are then introduced in 

each lip, uniting the cervical 
and vaginal mucous mem- 
branes. On each side a su- 
ture is passed in through 
the anterior vaginal and 
cervical flaps, out through 
the similar posterior flaps, 
and external to this such 
sutures as are inserted are 
necessary to bring in ap- 
position the raw surfaces. 
The sutures are tied and 
superficial sutures intro- 
duced, if necessary, to 
adjust the edges of the 
wound nicely. The more 
accurate the adjustment, 
the less will be the subse- 
quent contraction. 

Single Flap Method. — 
Schroder's operation con- 
sists in making the denu- 
dation at the expense of 
the internal or cervical 
portion of each lip. This 
operation is preferable 
when the cervical mucous membrane is so diseased and h^^per- 
trophied as to render its retention for the formation of a flap 
undesirable. In this, as in the former operation, a lateral incision 
is made and the lips are everted. Instead of a cervical flap a 
transverse incision is made into the lip from within outward, 
at the level of the lateral incision, cutting half through the 
lip ; then a vertical incision to the junction of the cervical and 
vaginal mucous membranes. Two sutures unite the end of each 
flap to the corresponding cervical mucous membrane, and the 
remaining raw surfaces are adjusted by lateral sutures. 




Fic 



-Schroder's Single Flap Opera- 
tion. 



TRAUMATISMS. 



263 



337. After-treatment. — The after-care does not differ in 
the various operations upon the cervix. In the use of the 
chromic catgut suture no provision is made for its removal, 
but it is important to preserve it from becoming infected. Un- 
less the vaginal outlet is to be the seat of an operation, the 
vagina should be loosely packed with gauze, which should be 
removed in two or three days. The patient is kept in bed 
for two weeks, and then gradually permitted to resume her 
ordinary duties. Any pain should be relieved by the application 
of an ice-bag to the abdomen. The patient should void her 
urine, and the catheter should be used only when it is impos- 
sible for her to empty her bladder while in the recumbent pos- 
ture. Secure an evacuation of the bowels at least each alter- 
nate day. Avoid vaginal douches for the first forty-eight 
hours, affording the plasma 

opportunity to glue the appos- 
ing surfaces ; then use a douche 
of hot sublimate solution 
(i : 3000), formalin (i : 1500), 
or a I per cent, saline solution 
twice daily. 

Direct the patient to avoid 
worry or much exercise during 
the next menstrual period, 
and not to resume the sexual 
relation for one month. 

338. Lacerations of the 
Vagina. — Small tears of the 
anterior, posterior, or lateral 
wall of the vagina are not 
infrequent, and result in ci- 
catrices which produce more or less disturbance of the pelvic 
functions. Separation of the muscular wall can occur without 
lesion of the mucous membrane. Not infrequently the entire 
vagina is crowded away from its muscular attachments, so 
that it subsequently appears as a relaxed sac, falls into folds 
which drag upon the cervix, displace the uterus, or, when it is 
fixed, produce hypertrophic elongation of the cervix. The most 
frequent lesions are at the vaginal outlet, and involve that por- 
tion of the pelvic floor known as the perineum. These lesions 
of the vagina are so intimately associated with, and dependent 
upon, the condition of the perineum that their treatment will 
be discussed with the lesions of the latter, under the head of in- 
juries of the pelvic floor. Lesions of the genital canal, especially 
of the cervix and vagina, may be induced by long-continued 
pressure of the head of the child during a protracted labor. The 



1 

i -»1 


/ 1] 


r ^'ii r'^T^lBIB 


■^TJj 



Fic 



201. — Schroder's Operation Com- 
pleted. 



264 GYNECOLOGY. 

loss of tissue vitality will necessarily be dependent upon the 
severity and duration of the pressure. 

It may involve only the superficial structures, as an erosion 
or superficial sloughing, when the tissues may be regenerated 
or, if more extensive, there results contraction and stenosis 
or partial or complete obliteration of the canal, known as ac- 
quired atresia. Acquired atresia most frequently follows in- 
juries occurring during parturition, but it can be produced by 
irritating injections and severe inflammations. Atresia vaginse 
often occurs as a sequel of senile vaginitis. In one patient I 
found the entire vagina obliterated. The symptoms of such 
a condition are necessarily dependent upon the time of life 
at which it occurs. When it follows senile vaginitis, it often 
produces no symptoms outside those of marital inconvenience. 
During the menstrual life of the woman the symptoms are 
similar to those of the congenital variety. The patient suffers 
from menstrual molimina and a pelvic tumor follows. When 
the vagina is the seat of atresia, the condition is easily recog- 
nized, as is the uterine accumulation, if the obliteration occurs 
at the external os. W^hen the obliteration occurs at the internal 
OS, however, and the cervix is apparently normal, the diagnosis 
is more difficult, and the disorder may be confounded with 
fibroma uteri, malignant disease, or pregnancy. The careful 
analysis of the patient's history, associated with the examination, 
should aft'ord a reasonable suspicion as to its character. 

339. Fistulas. — Deep sloughs involving a portion of the 
genital tract occasionalh^ lead to perforation of one of the ad- 
joining viscera, and we then have a fistula. The anterior wall 
is the most frequently aft'ected, and, consequently, results in a 
urinary fistula, which may involve urethra, bladder, or ureter, 
and be associated with extensive destruction of vagina and 
cervix. Fistulae are divided into urinary, fecal, and genital. 

The genito -urinary fistulas are: 

1. Urethrovaginal. \ 

2. Vesicovaginal. ) 

3. Vesico-uterine. j (Fig. 202.) 

4. Ureterovaginal. \ 

5. Utero-ureterine. / 
The fecal fistulae are: 

1. Anovulvar. ^ 

2. Rectovaginal. V (Fig. 202.) 

3. Entero vaginal. J 

340. Etiology. — Genital cervicovaginal fistulae are most fre- 
quently caused by the accidents of labor. These lesions are 
of less frequent occurrence than formerly, the result of improved 
methods of delivery, by which the progress of the fetus is expedited 



TRAUMATISMS. 



2G5 



and the maternal parts are saved from long-protracted pres- 
sure. Fistulae are rarely the result of tearing, but generally 
follow a slough. Awkward use of instruments can result in per- 
foration of the bladder or the rectum, but such lesions present a 
marked tendency toward spontaneous recovery. 

Other causes of fistula are cancer involving the anterior 
or posterior vaginal walls, tuberculous disease, surgical opera- 
tions, ulceration from the presence of a vesical calculus, the pres- 
sure of a pessary, and abscesses or phlegmons. 

341. Symptoms. — The presence of a urinary fistula is recog- 
nized by incontinence of urine and by the appearance of urine 
in the vagina. A fecal fistula will permit the discharge of 
liquid feces and gas. A few days subsequent to her confine- 
ment the patient com- 
plains of being unable / ^ 
to retain her urine, or - - '* ' 
possibly it may come 
with a gush, following 
the partial or complete 
separation of a large 
slough. The parts are 
afterward continually 
bathed with urine, the 
skin becomes reddened 
and irritated, and the 
salts of the urine are 
deposited, increasing 
the irritation. The 
clothing of the patient 
is saturated with de- 
composing urine, caus- 
ing a disgusting odor. 
Partial continence 

may be present when the opening is small, when it is situated 
high in the vagina, or when it affects but one ureter. The in- 
fluence of a fecal fistula depends upon its size and situation. A 
small opening may permit the escape of the contents of the intes- 
tine only when they are liquid. The odor of the vaginal secre- 
tion is exceedingly offensive, so that the patient suffers an 
enforced retirement. 

342. Diagnosis. — Incontinence should at. once awaken a 
suspicion of a fistula. Large fistulae are readily recognized by 
vaginal palpation. Small fistula, associated with cicatricial 
contraction of the vagina, are often difficult to expose. The 
entire surface of the A^agina should be exposed with retractors 
or with a Sims speculum under a good light. If the opening 




Scheme Showins; Various Fistulae. 



266 



GYNECOLOGY 



is small, it will be revealed by injecting the bladder or rectum 
with milk or other colored liquid, when the opening will be 
observed as the liquid escapes into the vagina. 

This procedure affords a means for differential diagnosis 
between ureteric and vesical fistulas and between the rectal and 
enteric. The escape of clear urine into the vagina when the 
bladder is filled with a colored liquid demonstrates the ureter as 

the origin of the fistula. 
The introduction of a ure- 
teral catheter into the sinus 
and of a sound into the 
bladder permits the recog- 
nition of the intervening 
septum. If the opening is 
small and not visible, dry 
the surface and apply blot- 
ting-paper while the blad- 
der is being filled. The 
paper will be moistened at 
the side of the fistula (Pozzi) . 
The same object can be 
attained by packing the 
vagina with sterile gauze 
and injecting the bladder 
with colored fluid. The 
staining of the gauze will 
indicate the situation of the 
opening. In enteric fistulae 
the vagina is constantly 
bathed with liquid feces, 
and the appearance of the 
discharge is not affected by 
rectal enemas. There is 
an offensive vaginitis and 
the patient suffers from 
inanition. In supposed 
uretero-uterine fistula the 
position of the ureters 
should be examined by 
Sanger's method. (See Section 158.) It has been suggested that 
the patient urinate, then sit two hours upon a vessel, when a 
catheter is used; and if the quantity thus secured is equal to 
that in the vessel, there is a ureteric fistula. The collection has 
been obtained from separate kidneys. 

A fistula of one ureter may be inferred when, in spite of 
the periodical passage of urine through the urethra, the vagina 




Fig. 203. — Large Vesicovaginal Fistula with 
Prolapse of the iVnterior Vesical Wall 
through the Opening. 



TRAUMATISMS, 



267 



is constant^ bathed with urine ; a vesical fistula near the neck 
may permit of no accumulation of urine, while a small one in 
the upper part of the vagina may allow soiling of the latter 
canal only when the patient is recumbent. In the upright posi- 
tion the desire to evacuate occurs before it reaches the level of 
the fistulous opening. 

The most ready method of recognizing the ureteric fistula 
is by injecting the bladder 
with colored fluid. The con- 
tinuation of uncolored fluid 
in the vagina demonstrates 
that we are not dealing with 
a vesical opening. 

No operation should be 
attempted for rectal fistula 
without exclusion of rectal 
stricture. 

343. Prognosis. — The 
curability of a fistula de- 
pends upon its cause, situa- 
tion, size, and duration. 
Those produced by cancer 
are a part of the progress of 
the disease, and are incur- 
able unless the disease can 
be removed. Spontaneous 
recovery of a punctured or 
incised fistula is prone to 
occur under proper cleanli- 
ness, but an old sinus with 
hard, cicatricial edges re- 
quires surgical interference. 
An opening in the base of 
the bladder is more readily 
relieved than one in the 
upper part of the vagina Fig. 
or one in the urethra. 
Vesico-uterine fistula are 

particularly difficult, and the uretero vaginal and uretero-uterine 
fistulce are most trying. 

344. Treatment. — The methods of treating vaginal fistulas as 
now recognized may be considered as : 

1. Cauterization. 

2. Denudation and suture of the edges of the fistula. 

3. Flap-splitting, fiap-sliding, and suture. 

4. Flap-formation and sutures. 




204. 



-Denudation of the Edges of the 
Fistula. 



268 



GYNECOLOGY. 




345. Cauterization is applicable only to fistulse of small size 
and where but little cicatricial tissue exists. The thermocautery 
is the preferable means, although caustic potash, chlorid of zinc, 
or one of the stronger acids can be employed. 

346. Preliminary treatment is important, whatever the method 
of operative procedure. The urine should be rendered non-irritat- 
ing by the administration of benzoin salts or salol. 

K . Ammon. benzoat. ^iij 

Tinct. hyoscyami, f ^iss 

Ext. buchu, r ad f 5 ij. M. 

SiG. — f 3 j in water three or four times daily. 

This prescription should be accompanied by the ingestion of 

large quantities of water. 
Salol, gr. ij-iij, may be 
given with a glass of hot 
water three or four times 
daily. Hot or soothing 
vaginal douches should be 
freely employed, such as a 
solution of sodium hypo- 
sulphite (oiv, aq. Oj) or 
weak solutions of the lead 
salts. If there is an incrus- 
tation of the lime salts 
about the orifice and over 
the vagina, employ a solu- 
tion of dilute nitric acid 
(gtt. j, mucilage water fSj). 
Cicatricial bands should be 
incised and stretched; the 
vaginal walls should be in- 
cised, to diminish traction 
upon the edges of the fistula 
when sutured. The cica- 
trization may be overcome 
by having the incisions heal 
while a Gariel pessary or 
a colpeurynter is worn. 
Bozeman employed vaginal 
obturators of plated cop- 
per, which, when worn, 
distended the vagina and 
The intestinal canal should 



% 






/ 



Fis:. 20 s. — Sutures Introduced. 



gave more room for operation, 
be thoroughly evacuated. 

347. Vesicovaginal Fistula. — Injuries of the vesicovaginal 
septum are the most frequent undoubtedly because the tissues 
are more likely to be compressed between the advancing head 



TRAUMATISMS. 



269 



and the pubic symphysis. The operation of vivifying and sutur- 
ing the edges was revived, perfected, and rendered successful 
by Sims. After thorough cleansing and disinfection of the 
vagina and the bladder the patient is placed in the semi- 
prone position, upon her back, with her limbs well flexed, or 
in. some cases the fistula may be rendered more accessible by 
placing her upon the abdomen and elevating the pelvis. The 
perineum is retracted and the edges of the opening are rendered 
tense by suitably applied 
double tenacula, which are 
held by assistants. The 
denudation is performed 
with knife or scissors, pref- 
erably the latter, as the 
tissues bleed less. The den- 
udation is accomplished at 
the expense of the vaginal 
surface, exercising care to 
avoid injury to the vesical 
mucous membrane. The 
mucous membrane is seized 
with forceps at one side and 
the denudation is performed 
with the attempt to com- 
plete the circuit with the 
one strip. Having secured 
an equal denudation upon 
all sides, about one centi- 
meter in Avidth, the sutures 
are introduced. They are 
inserted about one centi- 
meter apart, introducing 
and bringing them out 
about five millimeters from 
the edges of the denudation 
without permitting any su- 
ture to penetrate the vesical 
mucous membrane. The 

sutures may be introduced anteroposterior, transverse, X or Y 
shaped, according to the opening, that direction being chosen 
which will produce the least traction upon the tissues . The sutures 
may be silk, catgut, sillavorm-gut, or silver wire, preferably the 
latter two. After the sutures are all in place the bladder should 
be irrigated in order to remove all clots, and the sutures should 
be tied, twisted, or secured with perforated shot, exercising care 
not to draw them tight enough to strangulate the inclosed tissues. 




Fio;. 206. — AVound Closed. 



270 



GYNECOLOGY. 



After securing the sutures it is well to inject the bladder to make 
sure that no small opening remains. In large fistulae care must 
be taken not to injure or constrict the orifice of a ureter. These 
canals may open upon the surface of the fistula, when the vesical 
surface of the ureter should be split several days before the opera- 
tion and the surfaces be kept open by the frequent use of a probe. 
348. Flap-splitting or Flap-sliding. — The loss of structure by 

denudation in large fistula 
is not infrequently a serious 
sacrifice of tissue, and has 
led to the practice of secur- 
ing fresh surfaces by split- 
ting the edges of the fistula. 
The vesical and vaginal sur- 
faces are divided through 
the cicatrized margin to any 
required depth, according 
to the size of the fistula. 
AVhen the opening is small, 
it can be closed by a purse- 
string suture. The suture of 
sillavorm-gut or silver wire 
is passed through the vagi- 
nal flap within the vesico- 
vaginal septum, and brought 
out in the vagina directly op- 
posite its point of entrance, 
reintroduced near its exit, 
and made to traverse the 
remaining side of the open- 
ing, and brought out near 
the original entrance. This 
suture, tied, turns the vagi- 
nal flap outw^ard and the 
A^esical inward. When the 
size of the opening renders 
it desirable to close it upon 
a line, the vesical flaps are 
closed with animal sutures, preferably of catgut. The vaginal 
flaps may be closed with silk or silkworm-gut. 

Walcher advocates first cutting away the cicatricial tissue, 
then separating the vaginal and vesical surfaces. This procedure 
secures greater mobility of the internal flaps, which are closed 
with catgut by the Lauenstein stitch. The needle is introduced 
on the raw surface and brought out on the line of demarcation, 
midway between the raw surface and the vesical mucous mem- 




Fig. 207. — Method of Suturing to Decrease 
the Tension upon the Sutures. 



TRAUMATISMS. 



271 



brane, and the reverse in the opposing vesical flap. After these 
sutures are tied, closing the bladder, the vaginal flaps are sutured. 
E. R. Corson (Savannah, Ga.) expedites the formation of the flaps 
and the introduction of sutures by the use of a portion of an india- 
rubber ball. A strong silk cord is passed through the shank of a 
shoe-button which has been made to pierce the center of a portion 




Fig. 209. — Wound Closed. 



Fig. 208. — Showing Continuation of 
Suturing to Close Fistula with 
Incisions to Decrease Tension 
with Suture Introduced on Left 
Side to Close the Secondary- 
Opening. 



of a rubber ball ; this, folded, is carried by forceps through the fistu- 
lous opening. Traction upon the string draws down the opening, 
exposing its edges. The ease with which the vaginal and vesical 
portions of the septum can be separated renders flap-splitting a 
very ready method for closing large fistulas. This separation can 
be done with impunity, because the circulation of the two surfaces 
is not interdependent. The incision through the vaginal portion 



272 



GYNECOLOGY. 



is preferably made upon a 




Fig. 2IO. — Fistula Preparatory to Split- 
ting into Vesical and Vaginal Flaps. 



vertical line. Beginning at one side 
of the fistula, one blade of a 
suitably curved scissors is in- 
serted between the two layers 
as exposed by the vertical in- 
cision (Fig. 2ii) and carried 
completely around the fistu- 
lous opening, and the walls are 
separated by blunt dissection. 
The dissection may be made 
with the knife, first by a ver- 
tical incision through the fis- 
tula and then dissecting up a. 

large flap upon either side. The separation may extend to and 

even through the peritoneum, where necessary, to secure addi- 
tional tissue to close the 

opening. In closing a 

large fistula the sutures 

in the vesical wall are pref- 
erably introduced upon a 

transverse line, and as 

they are buried they 

should, therefore, be of 

chromic catgut or of fine 

silk. The edges of the 

fistula should be inverted 

into the bladder. Each 

extremity should be se- 
cured by a suture, the end 

of which, left long and 

used as a tractor, permits 

the intervening portion to 

be rapidly closed with a 

continuous suture. These 

sutures should not pierce 

the epithelial surface of 

the vesical mucous mem- 
brane. The closure of 

the vesical wall should be 

followed by distention of 

the bladder with a warm 

saline solution to make 

sure that it is tight. The 

vaginal wall should then 

be closed by a vertical line 

of suturing, which may be continuous or interrupted 




1 

i 



\ 



^v( 



\ 







r 



Fig, 2 11, — Demonstration of Flap-splitting, 



as the 



II 



TRAUMATISMS, 



273 



operator prefers. In introducing these sutures the bladder sur- 
face should be included, to prevent the accumulation of serum 
or blood between the surfaces. 

The fact that the vagina has been so destroyed that it will 
not afford material to cover the vesical wall need not deter the 
operator from emplo3^ing this method, as flaps can be taken 




Fig. 212. — Suture Introduced into 
Vesical Flap. 



Fig. 213. — Suttire Tied in Vesical 
Flap Introduced in Vagina. 



from the labia or from the inner side of the thighs to complete 
the vaginal wall. 

M. C. i\IcGannon, of Nashville, very ingeniously closed a 
fistula in a woman who had a laceration of the rectovaginal 
septum half-way to the cervix, and the anterior vaginal wall and 
base of the bladder were gone. He dissected the bladder away 
from the uterus and pushed the peritoneum off until he could 
bring the flap down to the lower segment, and closed it with fine 
catgut. After closing the 
bladder, the surface was cov- 
ered as much as was possible 
with the remaining portion 
of the vagina. A large sur- 
face was left uncovered for 
cicatrization. The left ureter 
had been included in the 
bladder, but the orifice of 
the right was situated so 
high in the vagina that it 
was inaccessible, but was 

subsequently conducted to the bladder by an artificially con- 
structed conduit. A year later her condition was good, with 
perfect control of the urine. 

In extensive fistulse Trendelenburg advocates making a trans- 
verse incision ten centimeters long through the abdominal 
walls, and a transverse incision through the bladder, just below 
the peritoneal junction. The upper edge of the vesical wound 
18 




Wound Closed. 



274 



GYNECOLOGY. 



is temporarily stitched to the corresponding abdominal, and the 
lower edges of the bladder are held open with sutures. The 
edges of the fistula are trimmed and the sutures so introduced 
that their ends can be brought out and tied from the vagina. 
The anterior vesical wound is closed around a drainage-tube, 
gauze is placed in the prevesical space, and both are brought 
through an opening in the abdominal wound, the remaining por- 
tion of which is closed with sutures. 




Fig. 215. 



-Sutures Introduced to Close Vesical Surface, as Suggested by 
Walcher. 



Bardenheuer formed a flap by transplantation. He per- 
formed suprapubic cystotomy, and through the abdominal wound 
dissected the bladder away from the peritoneum as low as the 
fistula, separated the adhesions and cicatricial tissue, denuded 
the edges of the fistula and sutured them from the vagina, while 
the edges of the fistula were pressed together by the finger 
passed into the bladder through the suprapubic wound. The 



TRAUMATISMS. 



275 



abdominal wound is plugged with gauze and left open. By- 
utilizing a vesical flap the operation can be performed through 
the vagina, as described above. 

349. Flap formation is a procedure practised by Ferguson, 
of Chicago, and E. Stanmore Bishop, of Manchester, England. 
Ferguson made an incision with a scalpel through the vaginal 
mucous membrane three to six millimeters from the margin 
of the fistula. (Fig. 216.) This incision completely encircled 




Fig. 216. — Flap-formation as Suggested by Ferguson. 



the opening and extended to, but without injuring, the vesical 
wall. The wotmd was kept free from blood by a stream of 
sterilized water. This procedure formed a circumferential flap, 
hinged by the vesical mucous membrane, which, ttimed into 
the bladder, formed a roof for the raw surface and was held 
in that position by a continuous fine chromic catgut suture 
so inserted that it did not pierce the mucous wall of the organ. 



276 



GYNECOLOGY. 



(Fig. 2 20.) The narrow strip of vaginal tissue, which from 
its density retained the stitches well, became a part of the 
bladder-wall. The fistulous opening was thus closed and made 
water-tight. The operation was completed by suturing the 
vaginal walls with silkworm-gut or silver wire. (Fig. 181.) 
Bishop ingeniously inserts four sutures into the edges of the 
flap as constructed by Ferguson, and with a pair of forceps 
passed through the urethra drags these sutures, previously 




Fig. 217. — Flap Turned in and Vesical Opening Closed, 



knotted, out through that canal. The funnel thus formed is 
closed with a suture from the vagina and the vaginal walls are 
sutured over it. The advantages justly claimed for this plan 
are: first, there is no loss of tissue; second, a broad surface is 
secured for apposition; third, there is a projection into the 
bladder at the site of the opening which decreases the danger 
of leakage and infection; fourth, in case the ureter opens into 



TRAUMATISMS. 



277 



the fistula, it affords an opportunity to turn it into the bladder; 
fifth, it decreases the danger of primary and secondary hemor- 
rhages ; sixth, in large openings it affords the best opportunity 
to secure relaxation by incision or sliding flaps; seventh, it is 
applicable to fistulse of the bladder, urethra, or rectum. 

350. After-treatment. — The vagina, thoroughly cleansed, 
should be lightly packed with iodoform gauze, which should 
remain for two or three days. Continuous drainage should be 




Fig. 21S. — Introduction of Vaginal Sutures. 



secured by the introduction of a self-retaining catheter into 
the bladder. This should be removed daily, for the purpose 
of cleansing. At the end of eight days it should be removed 
permanently; but the patient should be catheterized four times 
daily for the next week. The vagina should be irrigated with 
an antiseptic solution twice daily after the third day, and this 
should be continued for the greater part of three weeks. The 
sutures should be removed on the fifteenth dav. 



278 



GYNECOLOGY. 



351. Closure of the Vagina. — Colpocleisis. — Episiostenosis. — 

Large fistulas in which the base of -the bladder is destroyed 




Fig. 219. — Section Showing Projection upon Vesical Surface. 




Fig. 220. — Self-retaining Catheter. 




Fig. 221. — Vesico-uterine Fistula. 

may be indirectly obliterated by closure of the vaginal orifice, 
thus making the vagina a part of the urinary reservoir. ^ A 
ring of tissue two centimeters broad is removed from the vaginal 



TRAUMATISMS. 



279 



orifice. In the dissection the parts should be kept on the 
stretch and the tissue should be dissected from above down- 
ward. A sound in the urethra and a finger of an assistant in 
the rectum will greatly facilitate the denudation of the anterior 
and posterior walls of the vagina. The sutures should be passed 
from below upward and from above downward, exercising 
the greatest care that neither rectum, bladder, nor peritoneum 
shall be perforated by the sutures. The denuded surfaces 
should be brought in ac- 
curate apposition and the 
overlapping of freshened 
surface with mucous mem- 
brane or skin should be 
strictly avoided. This pro- 
cedure, while it affords a 
means of relieving inconti- 
nence of urine in otherwise 
desperate cases, has many 
disadvantages. Impregna- 
tion is no longer possible; 
coition can be practised 
only when obliteration has 
occurred high in the va- 
gina. The menstrual blood 
not infrequently excites 
violent cystitis, resulting in 
pyelonephrosis and the for- 
mation of vesical calculi. 
The urine may cause metri- 
tis or tubal, ovarian, and 
even peritoneal inflam^ma- 
tion. Rectovaginal fistula 
has been made to supple- 
ment this operation when 
the neck of the bladder has 
undergone such injury as to 
render the patient unable 
to retain the urine. The 
majority of such cases have been unsuccessful, owing to the irrita- 
tion of gas and feces and the inclination of the fistula to close. The 
fistula is very rare which cannot be closed by flap-sliding, as the 
vesical and vaginal surfaces are easily separated and the vaginal 
wall when deficient can be replaced by flaps from the vulva, 
and inner sides of the thigh. 

352. Urethrovaginal fistula is very infrequent. It is char- 
acterized by the discharge of urine into the vagina during; 




Fig. 



-Colpocleisis. 



280 



GYNECOLOGY. 



micturition. The flap-splitting operation affords the most satis- 
factory method of closing it. 

353. Vesico-uterine fistula permits the escape of urine 
through the external os. It may result from a slough follow- 
ing a tedious labor, and from lacerations of the cervix when 
the tear has extended through the anterior lip. The tear may 
have been incomplete, not extending through the os, or the 




Fig. 223. — Closure of Fistula after Its Exposure by Incision through Anterior 

Vasfinal Fornix. 



fissure may have healed with the exception of the communica- 
tion between the bladder and cervix. The only condition 
with which such a fistula can be confused is the uretero-uterine. 
The latter fistula is rare. Upon injecting the bladder with 
a colored fluid (a solution of pyoktanin) its emergence from 
the OS demonstrates the presence of a vesical fistula; the con- 
tinuance of clear fluid, a ureteral. In an opening of consider- 



TRAUMATISMS. 



281 



able size the sound will pass directly into the bladder, where 
it can be recognized by another inserted through the urethra. 
Treatment. — The fistula may be exposed by dilating the 
cervix with a laminaria tent. In a uretero-uterine fistula this 
procedure would be accompanied with renal pain, nausea, and 
vomiting, due to the obstruction of urine from the kidney 
con*esponding to the affected ureter. The fistula may be 
denuded and closed from the cervical canal, but the opera- 
tion is attended with difficulty. The preferable procedure is 
to cut through the anterior fornix of the vagina and dissect 
the bladder from the cervix, when the opening can be exposed 
and sutured ; the vaginal wound is subsequently closed with silk 

or catgut. It is desirable that the 
peritoneum should not be opened, 
though its incision, with proper 





Fig. 224. — Fistula Closed into Va- 
gina. Uterine Opening Re- 
mains, Which Will Close of 
Itself. 



Fig. 225. — Section Showing Sutiire for 
Hysterocleisis. 



precautions, does not materially affect the result. AVhen the 
bladder-wall is thin, Herr advises cutting through the cervix 
and reinforcing the bladder- wall with cervical tissue. Sanger 
split the cervix of a patient in whom the sinus opened laterally, 
sutured the side on which the fistula occurred, as in an Emmet 
operation, and then sutured the other side. 

354. Hysterostenosis or hysterocleisis (Fig. 227), the denu- 
dation and suturing of the cervix, is possible, but the menstrual 
flow may produce serious cystitis, and contraction of the fistula 
may result in severe pain and distress during menstruation. 
Both tracts will be subject to irritation and descending infection, 
producing upon the genital side, endometritis, salpingitis, and 



282 



GYNECOLOGY. 



peritonitis; upon the urinary, ureteritis and pyelitis. When 
we consider that the opening can be exposed by dissecting the 
bladder from the cervix, one can hardly conceive the selection of 
hysterocleisis as ever justifiable. 

355. Vesico-uterovaginal (Cervical) Fistula. — A portion of 
the cervix, with a considerable portion of the vaginal septum, 
may be destroyed, and the remaining walls may be so thin as to 
render its closure difficult or dangerous, owing to proximity of 




Fig. 226. — Closure of Fistula within Cervical Canal after Splitting Cervix. 



the peritoneum. In such cases the anterior lip of the cervix 
(Fig. 228) may be denuded and turned into the bladder, using 
it as a plug to fill up the opening. 

When the fistula has developed at the expense of the anterior 
cervical lip to such an extent that it will not afford sufficient 
structure to close the opening, the posterior lip may be freshened 
and utilized. (Fig. 229.) This procedure necessarily X->roduces- 



TRAUMATISMS. 



283^ 



disturbance because of the continuance of menstruation. A 
preferable method is to separate the vesical wall from the cervix 
and secure sliding flaps, which can be closed as in figure 230. 

356. Ureterovaginal-ureterocervical Fistulas. — Lesions of the 
ureter are less frequent than the other forms of fistulas. Par- 
ticipation of the ureter in the vesicovaginal opening is much 
more frequent. Uretero vaginal fistulas are more frequently 
the result of injuries sustained during the performance of hys- 



# 





Fig. 227. — Hysterocleisis. 



terectomy. The diagnosis has been considered. (See Section 
342.) The cervical fistula is very rare. The thickened ureter 
can generally be traced to the cervix by the finger in the vagina. 
Treatment. — Relief from the discomfort produced by these 
fistulae may be accomplished by resort to one of several methods,. 
viz.: 

1. Anastomosis through the vagina. 

2. Anastomosis through the abdomen. 



284 



GYNECOLOGY. 



3. Ligation of the ureter. 

4. Introduction of the ureter into the rectum or colon. 

5. Nephrectomy. 

Anastomosis through the vagina may be accomplished by first 
establishing an artificial vesicovaginal fistula alongside the ureter. 
This opening, and the ureter opened for the distance of nearly 
two centimeters of its intraparietal border, are prevented from 
closing by the subsequent daily use of the sound. After perma- 
nent cicatrization has taken place, the vesicovaginal fistula, 
which now includes the ureteral, is closed by denudation and 
suturing the new surfaces (Simon). The vesicovaginal fistula 
may be formed by an oval incision. A small elastic catheter 
can be passed into the bladder, through the urethra, from it 
through the fistula into the vagina, and then into the orifice of 




Fig. 228. — Anterior Lip of Cervix 
Utilized to Close the Fistula. 



Fig. 229. — Vesico-uterovaginal Fis- 
tula in which the Posterior Lip 
of the Uterus is Utilized to Close 
the Opening. 



the ureter. With the patient in the genupectoral position the 
vaginal mucous membrane is denuded around the fistula. To 
close the opening, the sutures are placed parallel to the catheter, 
which is left in place for several days (Landau) ; or a buttonhole 
incision may be made, removing two centimeters of the vesical 
mucous membrane in the direction of the ureter ; the vesical and 
vaginal mucous membranes are sutured to prevent closure, and 
a catheter is introduced into the bladder through the urethra and 
into the orifice of the ureter through the vesical fistula. An 
annular denudation is made about the fistula, leaving immedi- 
ately about it a zone of mucous membrane three millimeters in 
diameter. After suturing, the fistula with intact mucous mem- 
brane is turned into the bladder, where it forms a gutter-like 



TRAUMATISMS. 



285 



depression, into which the ureter opens (Schede). X. O. Werder, 
in a case of double ureterovaginal fistula following hysterectomy, 
made a transverse incision through the anterior vaginal wall 
into the bladder. The vaginovesical edges of the upper portion 
were sutured together, while the inferior border was united to 
the posterior vaginal wall, making a diverticulum to the bladder 
which controlled leakage. 

All these methods employ the formation of an artificial 
vesicovaginal fistula, which 
must ultimately contract. 
As the ureter is a distinct 
canal, capable of being dis- 
sected out of its bed, there 
seems no reason why it 
should not be loosened from 
cicatricial adhesions, drawn 
down, and introduced 
through an opening in the 
vesicovaginal septum. This 
procedure is applicable to 
either vaginal or cervical 
fistulse of this canal. In 
order to prevent compres- 
sion of the ureter a portion 
of the bladder-wall should 
be excised. The ureter is 
introduced into the bladder, 
the wound is carefully closed 
with sutures introduced to 
fix the wall of the ureter 
and thus insure its reten- 
tion. Care should be exer- 
cised that the ureter is not 
compressed, nor much, if 
any, of its surface left un- 
covered in the vagina. In 
ureterocervical fistulas the 
cervix should be split until 
the orifice of the ureter is exposed, when that structure can be 
drawn down and union accomplished in the manner just des- 
cribed. Obliteration of the vaginal orifice has been done after 
the establishment of a vesicovaginal fistula, but such a course is 
both unnecessary and undesirable. 

Anastomosis through the abdomen may be preferable in a nar- 
rowed cicatricial vagina, or when the lower extremity has under- 
gone inflammatory changes or is so embedded in exudation that it 




Fig. 230. — Vesical Wall Loosened and [Su- 
tured. Vaginal Wall Sutured in Oppo- 
site Direction. 



■286 



GYNECOLOGY. 



can not be readily brought down. Through the ordinary incision 
for abdominal section the intestines are drawn aside, exposing 
the line of the ureter. In ureterovaginal fistula its situation 
•can the more readily be recognized by the introduction of a 
catheter prior to the abdominal incision. The peritoneum is 
opened, the ureter is raised, its proximal portion is tied and 
dropped back, and the central end is introduced through an 
incision into the bladder and secured by sutures, as in the vaginal 
method. The anastomosis with the bladder should be on the 
corresponding side of the pelvis, and with as little tension upon 
the canal as possible. Should the ureter be so short as to cause 
tension in reaching the bladder, the latter should be drawn up 

and anchored by a few 
stitches to the side of the 
pelvis, so that no traction 
shall be made upon the 
ureter. In recent injury an 
anastomosis can sometimes 
be made between the di- 
vided ends of the ureter. 
The proximal end should 
be introduced into the distal 
one and secured by sutures. 
(Fig. 234.) If the ends of 
the ureter are unfavorable 
for this procedure and the 
renal portion too short to 
permit of its introduction 
into the bladder, the ureter 
may be tied with a double 
ligature and dropped back. 
The urine accumulates in 
the pelvis of the kidney until 
the pressure equals that of 
the blood, when secretion ceases. The ureter may also be intro- 
duced into the rectum or colon. The ureter should pass through 
the bowel obliquely. However, this procedure is very likely to 
be followed by serious conditions in both the urinary tract and 
the intestine. In the former, infection and suppuration of the 
pelvis of the kidney are prone to follow. The presence of urine 
frequently causes irritation and inflammation (colitis or proctitis) 
of the intestine. 

Nephrectomy is advisable when the long duration of the fistula 
has resulted in extension of infection to the pelvis of the kidney, 
and careful examination has disclosed that the other kidney is 
capable of carrying on the work of both organs. 




Fig. 



231. — Operation for 
Fistula. 



Ureterovaginal 



TRAUMATISMS. 



287 



357. Accidents of the Operation and Results. — Primary hem- 
orrhage of a serious character may result from an unusually large 
uterine artery, from vascular walls, or from injury of the vesical 




Fig. 232.— Vaginal Implantation of the Ureter into the Bladder. 

mucous membrane. Either compression or suture is the best 
means for its control, but its occurrence imperils the result of 
the operation. 

Secondary hemorrhage may take place between the third and 
fifth days, and should be controlled by the tampon. It may 



( 



288 



GYNECOLOGY. 



occur into the bladder, and may be discovered only after that 
organ is filled with clot. It gives rise to violent tenesmus, and 
its decomposition will be extremely prejudicial to the success of 
the operation. When it can not be removed by irrigation, inject 
a solution of pepsin or enzymol. If this procedure fails to 
afford relief, the urethra should be dilated and the clot broken 
up and removed with a blunt curet. If hemorrhage continues, 




Fi< 



233- 



-Abdominal Transplantation of Ureter for Ureterovaginal Fistula. 
B. Bladder. 



it will be necessary to remove the sutures and search for the 
bleeding vessel. 

IncUision of a ureter will cause nausea, vomiting, lumbar pains, 
and fever. The suspected suture should be immediately removed. 

Peritonitis may result from injury during the denudation 
or suturing, or from infection, when proper precautions have 
not been observed, or when there is coexisting pyelitis or cystitis. 

Calculi and calcareous concretions have formed upon silver 
wire, silk, or even catgut sutures. 

The results of the operation are generally most satisfactory. 
Death is of very infrequent occurrence. 



TRAUMATISMS. 



289 



358. Rectovaginal Fistula. — The methods of treatment sug- 
gested (Section 344) are equally applicable to the fecal fistulas. 
The last two methods, flap-splitting and flap-formation, are 
probably effective and most generally applicable in the great 
majority. 

In a small fistula a curvilinear or triangular trap-door may 
be raised, including the fistulous orifice; the opening in the 




Fis. 



234. 



-Ureteral Anastomosis. 



rectal wall is closed by very fine (eye) silk, which has been 
previously sterilized, or by chromicized catgut; one or several 
Lauenstein sutures may be used, being careful not to enter the 
rectum. The vaginal flap is then secured with sillavorm-gut 
sutures. In large fistulse a sagittal incision with lateral flaps 
is most satisfactory. The sutures are introduced as previously 
described. Flap-formation is very serviceable in closing rectal 

19 



290 



GYNECOLOGY. 



fistulas of considerable size; fiap-transplantation is rarely suc- 
cessful. 

359. An ano vulvar fistula can be closed from the vagina or 
perineum. Such a fistula is incised through its track, cureted, 
and the entire sinus closed by sutures. It is generally better to 
extend the incision to, but not through, the sphincter, and to 
close the rectal or anal surface with sutures from the perineal 
side, when failure to unite will not endanger the future value 
of the sphincter and will enable the operator to secure union 
by granulation through gauze packing. Small fistulas near 
the vulvar outlet can be closed as a part of the operation of 
perineorrhaphy. 



/ 


\ 


/ 


L,.. ... N 


/ *^ 


■PM. iiwm^.- 


/ M^ 


L \ 






V 








Fig. 



235. — Sagittal Incision for Fig. 236. — Lauenstein Suture in Recto- 
Rectovaginal Fistula. vaginal Fistula through Rectal Wall. 



360. Preliminary and After-treatment. — The bowels should 
be thoroughly evacuated by repeated purging for two or three 
days. During the same period vaginal douches should be 
given, and a thorough scrubbing of the vagina with a solution 
of creolin and soap should immediately precede the operation. 
However, no operative procedure for closing a fistula should 
be entered upon until careful rectal examination has demon- 
strated the absence of a possible rectal stricture as its cause. 
For several days prior to the operation, and for at least a week 
subsequently, the patient should be kept upon an animal broth 
diet, and the use of milk should be prohibited. The opera- 
tion should be preceded a few hours by thorough irrigation 
of the rectum, and continuous irrigation should be practised 



TRAUMATISMS. 



291 



during it. After the third day the bowels should be moved 
each alternate day. The sutures of silk should be removed 
upon the eighth day; silkworm-gut or silver wire may be per- 
mitted to remain for fifteen days. The patient should be con- 
fined to bed the greater part of three weeks, and the bowels 
should not be permitted to become constipated for a month. 

361. Entero vaginal fistulas have been cured by cauteriza- 
tion or by denudation and suture from the vagina, but closing 
the fistulous intestine through the open abdomen is preferable, 
when the vaginal opening will need no further consideration. 

362. Cervicovaginal Fistula. 
— A cervicovaginal fistula is one 
which arises as a result of rup- 
ture of the cervix during labor 
from a longitudinal tear, or the 
lower margins of which have 
become reunited. The tear may 
be a perforation of one lip of the 
cervix through which the fetus is 
extruded, and occurs where the 
cervix is hard, rigid, and unyield- 
ing. Such a condition of the 
cervix is sometimes the cause of 
the entire cervix being torn away. 
A fistula may also arise from 
faulty methods of repair of the 
lacerated cervix. I have seen 
such openings on both sides of 
the cervix where trachelorrhaphy 
has been attempted. The fis- 
tula doubtless sometimes arises 
from the use of sharp instruments 
in attempts at abortion. The 
opening of such a fistula is ex- 
coriated and filled with mucus. 

Treatment. — The correction 
of the condition is not always an easy procedure. The pref- 
erable plan is to incise the cervix through the opening, denude 
the margins, and close as in an ordinary operation of trachelor- 
rhaphy, but this is not always practicable and in some cases the 
amputation of the cervix may be demanded. 

363. Lacerations of the pelvic floor are a frequent lesion of 
parturition, and can occur from within outward through the 
vagina and vaginal portion of the perineum, leaving its in- 
tegumental covering intact. The injury is a separation or 
tearing-off of the muscular fibers from the sides of the vagina. 




Fisf, 



237. — Rectal Wall Closed by- 
Transverse Line of Sutures; Va- 
ginal by Vertical Line of Sutures. 



292 



GYNECOLOGY. 



Generally, the tear takes place through the integument of the 
perineum; sometimes it may extend through the entire struc- 
ture, the sphincter, and up the rectovaginal septum. Not 
infrequently it will be found that the injury has been quite as 
deep, but on one side of the rectum and anus, and leaves both 
intact. Less frequently it will thus extend on both sides of 
the anus. 

Naturally, the influence upon the subsequent appearance 

and function of the parts 
must vary with the extent 
and direction of the lacera- 
tion. A slight laceration, 
which involves only the 
anterior portion of the peri- 
neum, may heal without 
producing much, if any, de- 
formity. A deeper lacera- 
tion, by the action of the 
trans versus perinei muscles, 
permits the vaginal orifice 
to stand open, and presents 
a triangular appearance. 
The failure of the bulbo- 
cavernosi muscles longer to 
antagonize the coccygeus 
permits the anus to be 
drawn back. 

Laceration through the 
sphincter necessarily causes 
loss of control of the bowel- 
contents. (Fig. 239.) 

The deep laceration to 
one side of the anus leaves 
the levator ani unantagon- 
ized, and the parts are 
drawn to the opposite side ; 
when the tear extends upon 
both sides, the anus is de- 
pressed and drawn backward. The vulva stands open, and we 
can look into the vagina from three to five centimeters. 

364. Causes. — Injuries of the pelvic floor may arise, first, 
from conditions inherent in the mother; second, in the child; 
and third, in the course and management of the labor. Of 
the first class may be — (a) too great or too slight an inclination 
of the pelvis, which renders the mechanism of the fetal head 
imperfect; (b) sl small vulvar orifice with rigid muscles, or a 




Fig. 238. — Rccl<:)vai^inal Fistula Closed 
Operation of Perineorrhaphy. 



TRAUMATISMS. 



293 



large amount of fat in the perineum ; (c) high or a nterior situation 
of the vulva, making a long perineum, over which the child's 
head must be extended. 

Second, laceration may result from excessive size of the 
fetal head and shoulders or from relative disproportion to 
the size of the mother. 

Third, laceration may result from — (a) either too rapid or 
too tedious labor ; (b) vertex presentations when rotation occurs 




Fig, 239. — Rupture of Perineum into Rectovaginal Septum. 



into the hollow of the sacrum and an occipitoposterior position 
presents a longer diameter of the head at the outlet; (c) face 
presentations, in which the longest diameter of the fetal head 
presents ; (d) either incomplete or excessive flexion ; (e) faulty 
manual or instrumental interference. 

365. Degree or Extent. — Lacerations of the pelvic floor 
may be incomplete or complete, and are generally divided 



294 



GYNECOLOGY. 



into four degrees: First, a tear through the fourchet and to a 
sHght extent in the perineum; second, to the sphincter. These 
form the incomplete lacerations, while the complete are: third, 
the tear extending through the sphincter; and, fourth, up the 
rectovaginal septum. A rare form of laceration is the central 
rupture, in which the fetus passes through the perineum with- 
out tearing either the sphincter or the vulva. 

366. The results of the injury are necessarily dependent 




Fig. 240. — Cvstocele. 



upon its extent. The immediate effects are induced by the 
action of the injured or antagonistic muscles. The cicatricial 
tissue produces certain reflex nervous phenomena, which, 
however, are insignificant compared to the mental influence 
exerted by fecal incontinence. The laceration causes defective 
involution of the vagina and uterus, the defect in the muscular 
junction of the pelvic floor weakens the action and consequent 



TRAUMATISMS. 



295 



resistance of the pelvic diaphragm. The constantly varying 
pressure of the bladder and rectum, the increased abdominal 
pressure consequent upon straining at stool, and the abnormally 
heavy uterus lead gradually to displacement downward of that 
organ, or, if it is fixed by the condition of its pelvic attachments, 
to extrusion of the anterior and posterior walls of the vagina, 
and their consequent weight will produce hypertrophic elon- 
gation of the cervix. Thus Ave have cystocele (prolapse of the 




^^^I: 




Fig. 241. — Rectocele. 



anterior vaginal wall, and with it the bladder), rectocele (pro- 
lapsed posterior wall), partial or complete prolapse of the vagina, 
with elongation of the cervix, or procidentia, consequent upon the 
increased weight of subinvoluted organs and the diminished 
support resultant from the lesion under discussion. [ 

367. Treatment. — The proper course of procedure is to" so 
repair the injury as to restore as nearly as possible the normal 



296 GYNECOLOGY. 

condition of the pelvic floor. In slight lacerations restoration 
will be secured by keeping the patient quiet and the parts clean. 
The operative treatment may be primary, intermediate, or sec- 
ondary. 

368. By primary operation is understood the immediate repair 
of the laceration, or at least within twelve hours. The tear pre- 
sents a large, raw surface, and is frequently found with ragged, 
irregular edges. The vagina may have been torn and the soft 
parts pushed oft' until the perineum has split either through 
the sphincter or to one or both sides of the anus. The method 
of repair will depend upon the nature and extent of the lesion. 
The necessary instruments will be found in an ordinary pocket 
case — scissors, dissecting forceps, a needle-holder, and long and 
short curved needles. The suture material may be silkworm-gut, 
catgut, silk, or silver wire. The patient should be placed upon 
her back across the bed or upon a table, while an assistant 
holds each leg, flexed upon the abdomen. As the parts are 
benumbed by the stretching to which they have been subjected 




Fig. 242. — Right and Left Curved Scissors. 

an anesthetic may be omitted; but if the patient is very nervous, 
one should be employed. A rubber pad or a piece of mackintosh 
should be placed beneath the patient to prevent soiling of the 
bed and to direct the current of irrigating fluid into a receptacle 
upon the floor. Compress the uterus and cleanse it and the 
vagina of clots; cleanse the external surface with a disinfectant 
fluid, after having trimmed the vulvar hair in order to keep it 
from embarrassing the procedure. Place a pad of gauze or ab- 
sorbent cotton beneath the cervix to keep the vagina free from 
blood. Trim smooth the ragged edges of the tear and proceed 
to suture. Fine chromicized catgut is preferable, because it will 
not have to be removed, and it produces less annoyance during 
the care of the patient than does either silkworm-gut or silver 
wire. In slight lacerations and vaginal tears the use of the con- 
tinuous suture is satisfactory. In extensive laceration inter- 
rupted sutures oft'er advantages. Precautions should be exer- 
cised to leave no dead spaces in which blood may accumulate, 



TRAUMATISMS. 



297 



become infected, and produce sepsis. In a double tear which 
extends upon both sides of the rectum the needle should be 
entered from above, brought out in the sulcus, reentered, and 
carried upward through the vaginal mucous membrane, so that 
each suture lifts up the tissue. Care should be exercised to 
restore the position of the levator ani muscles by bringing their 
torn ends back in position. So far as possible the sutures should 
be brought out in the vagina, as they thus produce less pain. 




Fh 



243. — Incomplete Rupture of the 
Perineum. 



Fis:. 



244. 



-Simon-Hegar Method of 
Denudation. 



The necessary perineal suturing may be with continuous suture, 
inclosing but little of the skin. 

In laceration of the sphincter make sure that the ends of 
the divided muscle are secured and coaptated by the suture. 
When the tear has extended into the rectovaginal septum, the 
sutures may be brought out and tied in the rectum, or, what is 
probably preferable, the Lauenstein suture may be employed, 
with buried catgut. 

369. The advantages of the primary procedure are : first, if 
the operation is successful, the patient is spared the necessity of 



298 



GYNECOLOGY. 



a subsequent operation; second, with proper precautions she is 
much less hkely to suffer from infection, and convalescence is 
expedited; third, the sequelae of unrepaired injuries are avoided. 
370. Contraindications. — The primary operation is contra- 
indicated when the patient has been exposed to a prolonged labor 
and the tissues have undergone extensive fraying or bruising 
through prolonged manual or instrumental interference. It is 
also contraindicated when there is reason to believe that the 
wound has been exposed to some virulent infection. Even in 
such cases, when the laceration extends through the sphincter. 




Fig. 245. — Sutures Introduced to Close the Wound. 



the anus and rectal wall should be sutured, in order to afford 
security to the contents of the bowel. 

371. The intermediate operation is performed any time from 
twelve hours to a week following the labor. The delay may be 
occasioned by want of proper material at hand, or it may be 
due to the condition of the patient, who is suffering from such 
profound shock that it will seem unwise to resort to any imme- 
diate procedure. Probably the fifth day after labor is the most 
favorable period for repair of lesions of the pelvic floor, for the 



TRAUMATISMS. 



299 



uterus has at this date sufficiently contracted to render evident 
any lesion and any loss of vitality of the structures of the pelvic 
floor or exposure to infection. The genital tract should be care- 
fully cleansed, the raw surfaces wiped with a gauze sponge, any 
ragged surfaces trimmed, and the surfaces sutured as for the 
primary operation. 

372. Secondary Operation. — This operation is preferably not 
performed for at least two months subsequent to delivery, in 




Fig. 246. — Garrigues' Modification of the Hegar Operation. 



order to permit involution and cicatrization to become accom- 
plished. In preparation, particularly when the tear is complete, 
the bowels must be thoroughly evacuated. Castor oil, a saline, 
or compound licorice pow^der should be given several days or a 
week before the operation and repeated at intervals of from 
twenty-four to forty-eight hours, in order to insure thorough 
evacuation of all hard, scybalous masses. The diet should con- 



300 



GYNECOLOGY. 



sist largely of animal broth, while milk should be absolutely 
excluded. The evening and morning before the operation the 
lower bowel should be cleansed with large enemas. The last 
enema should be given at least three hours before the time fixed 
for the operation. Patients should be prepared (Section 182), 
and the following instruments sterilized: a scalpel; right and 
left curved scissors, as well as scissors curved on the flat ; three 
double tenacula; eight pressure forceps; one long, rat -toothed 
dissecting forceps; a needle-holder; and two long and two short 





Fig. 247. — Upper Part of Wound 
Closed; Last Stitures Introduced. 



Fig. 248. — Wound Completely 
Closed. 



curved needles, all threaded with carriers. The suture material 
may be silk, silkworm-gut, catgut, or silver wire. In extensive 
laceration the silkworm-gut is preferable, for the reasons, first, 
that it, being more pliable, causes less pain during convalescence 
than wire, and, second, it is much less likely to become infected 
than either silk or catgut. 

Incomplete laceration (Fig. 243) may be repaired by a simple 
denudation of the torn surfaces (Fig. 244). As cicatrization has 



TRAUMATISMS. 



301 



resulted in contraction, it is necessary to extend the denudation 
of the vagina above the scar tissue. The further backward the 
rent extends, the higher into the vagina the denudation must 
be carried. The hne of denudation extends posteriorly from the 
junction of the mucous membrane and skin at the top of 
the old posterior commissure across in front of the anus to a 
corresponding point upon the opposite side, while an angle ex- 
tends up the vagina above the tear. The completed denudation 





Fig. 249. — Lauenstein Suture, 



Fi< 



o. — Rectum and Vagina Closed 
with Lauenstein Suture. 



presents a resemblance to the body and wings of the butterfly, 
and is designated the Simon-Hegar denudation. (Fig. 244.) 

The sutures are introduced about three millimeters from the 
margin of the wound, buried beneath the denuded surface, and 
brought out at a corresponding point upon the opposite surface. 
The sutures in the vaginal angle are first secured, and then the 
perineal. (Fig. 245.) The sutures when tied produce less discom- 
fort than if secured by compressing perforated shot upon their 



302 



GYNECOLOGY 



ends. The quill or bar suture was formerly much favored. It 
consisted of a quill placed in the loop of a double suture upon 
one side, the ends being tied over a second quill upon the oppo- 
site side, or the ends of a suture were passed through openings 




Fig. 251. — Hildebrandt's Method of Suturing. 



in a bar and secured by shot. The two quills or bars served 
for call the sutures, while the skin edges were united by super- 
ficial sutures. The suture caused so much pain that it has been 
largely discontinued. 



TRAUMATISMS. 



303 



A slight exaggeration of the denudation just described can be 
applied to the restoration of a complete laceration. The sutures 
must then be vaginal, rectal, and perineal. The latter are intro- 
duced after the former are placed. The rectal sutures of catgut 
are brought out into that canal. Care must be exercised in the 
introduction of the first perineal suture that it shall accurately 
bring the ends of the sphincter ani in apposition. 

Garrigues modified the Hegar operation by the following 
procedure (Fig. 246): According to the extent of the laceration 
and relaxation of the vagina and perineum the vagina is seized 
with a double tenaculum at a point in the median line more or 




Fig. 252. — Hildebrandt Suture Closed. 



less removed from the cervix. A point upon each labium ma jus 
is secured at such a distance from the clitoris as to permit of 
coition. The parts are rendered tense, the points are connected 
by an incision, and the intervening triangular surface is denuded. 
This denudation is carried downward to the margin of the skin 
and mucous membrane. With the vulva separated the denu- 
dation presents a triangular surface. 

The denudation is most rapidly accomplished by introducing 
one blade of curved scissors beneath the membrane at the point 
determined upon in the one labium and carrying it around the 
vaginal outlet to a similar position opposite. The central part 



304 



GYNECOLOGY. 



of this incision is picked up with forceps, cicatricial bands cut, 
and the finger pushed beneath this flap to the desired height. 
The tissues are pushed off laterally, and the triangular section 
is removed. It has the advantage that it is more than a denu- 
dation. It is a resection, and, therefore, permits the more accu- 
rate union of fascia and muscular structure. 

The sutures are introduced from above downward, about six 
millimeters apart, deep and superficial alternating, the latter 




Fig. 253. — Heppner's Figure-of-8 Suture. 



passing only through the edges of the mucous membrane. The 
four upper sutures are transverse; the remainder dip down- 
ward at the central portion, and, when tied, lift up the relaxed 
wall. The sutures are thus introduced and tied one after 
another until the remaining denuded surface forms an ellipse, 
the upper and lower borders of which are of equal length. (Fig. 
247.) Then a silkworm-gut suture (10) one centimeter above 
the posterior commissure is carried deeply beneath the wound 



TRAUMATISMS. 



305 



two-thirds the width of the denudation, and emerges at a similar 
point upon the opposite side. A second suture (ii) is inserted 
midway between this suture and the outer margin; passing 
beneath the denuded surface it emerges upon the vagina to 
the left of the median line, is reintroduced, and comes out 
equally distant from the first suture upon the right side. The 
last suture, introduced near the extremity of the denuded 
surface, appears in the vagina midw^ay between the second 
suture and the external denuded angle, reenters upon the op- 





Fig. 254. — Martin Suture to Close the 
Rectal Opening. 



Fig. 255.- 



-Martin Suture Con- 
tinued. 



posit e side, and emerges upon the right labium. These three 
sutures are all introduced and the surface is irrigated, when 
they are secured. 

In my judgment, the employment of the continuous chromic 
catgut suture is far more satisfactory. It can be so introduced 
as to lift up the pelvic floor, and should include the edges of 
the levator ani muscle and the overlying fascia. If the floor 
is much relaxed, the muscle and fascia can be sutured sepa- 
rately and the mucous surfaces be closed over it with a con- 
20 



306 



GYNECOLOGY. 



tinuous suture. This method of suturing greatly expedites 
the operation and has the advantage that it leaves no sutures 
(fig- 255) to be removed. 

'^Lauenstein's Method of Suturing. — This method of intro- 
ducing the sutures was devised to prevent their infection by 
the rectal and vaginal discharges. The sutures, of catgut or 
fine silk, are introduced in the denuded surfaces, including 
about five millimeters of the tissue intervening between the 




Fig. 256. — Denudation for Freund's Operation. 



borders of the rectal and vaginal mucous membranes respec- 
tively. (Fig. 249.) These are necessarily buried sutures. 
The remaining portion of the denuded surface is closed by 
silver wire from the perineum. (Fig. 250.) 

Hildehrandt makes the denudation trefoil in shape. (Fig. 
251.) The sutures are, for the most part, cutaneous. The 
vaginal sutures are first introduced ; next the rectal, and, finally, 



TRAUMATISMS. 



307 



the perineal. 12^^ (Fig. 252.) This method of suturing obliterates 
dead space and decreases the danger of abscess. 




Fig. 257. — Sutures Inserted in Rectal Wall and Lateral Vaginal Angles. 




Fig. 258. — Vaginal Angles and Rectal 
Wall Closed. Suture in Place for 
Perineum. 




Fig. 259. — Denudation Completely 
Closed. 



Heppner accomplishes the same object with a figure-of-8 
suture, which closes both vaginal and perineal surfaces. (Fig. 

253-) 



308- 



GYNECOLOGY. 



Martin more rapidly, and with a less complicated pro- 
cedure, meets the difficulty. (Fig. 254.) He, with a con- 
tinuous catgut suture, unites the intestinal wound from the 
rectal surface; when he reaches the anus, with the same suture 
in a contrary direction he superimposes a layer up to the superior 
angle of the vagina, and, if the denudation is deep, a third layer 
before the vaginal and perineal surfaces are united. (Fig. 255.) 

Freimd has emphasized the necessity of securing such a 




Fig. 260. — Emmet's Operation. Surface Denuded and Lateral Sutures in 

Place. 



denudation as would reproduce the original appearance of 
the tear. This, if there is a cicatrix, which presents the appear- 
ance of 00, the laceration from which it has contracted may 
be represented by figure 256. He incises the posterior column 
of the vagina at a certain distance from the scar and carries 
the bistoury backward along the sides of this column, circum- 
scribing the cicatrix in the vagina and upon the labia majora 



TRAUMATISMS. 309 

(Figs. 257, 258, and 259), and completes the denudation as in an 
ordinary operation. The Hne which corresponds to the rectum 
is sutured, then each edge of the posterior vaginal column is 
united to the external margin of the denuded surface. The union 
of the lines forms the vulvar and perineal surfaces. 

Emmet's operation is of especial value in relaxation of the 
posterior vaginal wall, and its purpose is to expose the fascia 
and so to introduce the sutures as to fold in the slack and lift 




-^ 



Fig. 261. — Emmet's Operation. Lateral Angles Closed and Perineal Suture 

Introduced. 

Up the perineum, bringing the parts more completely under 
the control of the levator ani muscle. AAath the labia separated 
by the hands of assistants the summit of the protruding recto- 
cele is seized with a double tenaculum; two other tenacula 
are placed one upon each of the caruncula, and a fourth upon 
the commissure of the vulva. When these are separated, 
they constitute a quadrilateral surface. These instruments 
are employed to render the parts tense, and the lines between 



310 



GYNECOLOGY. 



them are employed as the boundaries of the denudation. The 
intervening surface is completely denuded. (Fig. 260.) The 
sutures are then introduced in triangles, beginning in the sulcus 





Fig. 262. — Emmet's Operation 
Completed. 



Fig. 263. — Emmet's Operation for Com- 
plete Laceration. 




Fig. 264. — Suture to Unite the Ends of the Sphincter. 



TRAUMATISMS. 



311 



upon either side. The sutures introduced form a double triangle ; 
a suture joins the summit of denudation upon each side with 
the apex of denudation of the posterior column. This is called 
the crown stitch. (Fig. 261.) A number of perineal sutures 
are then used. By this method the majority of the sutures 
are within the vagina. The tying of the sutures lifts up the 
pelvic floor and brings the posterior segment of the pelvic 
floor more closely in contact Avith the anterior. (Fig. 262.) 




Noble modifies this operation by carrying his denudation higher 
upon the posterior column, by splitting the fascia and exposing 
the levator ani muscles. In suturing, he pulls out the muscle 
and secures it with not only the lateral, but also the central, 
sutures, or those below the crown suture. This brings the 
muscles in contact in front of the rectum and insures a strong 
support to the pelvic floor. 



312 



GYNECOLOGY. 



Emmefs operation for complete laceration has for its first and 
principal aim the restoration of the sphincter ani. The first 
suture is introduced and brought behind the ends of the torn 
sphincter, which have been carefully exposed in the denudation. 
(Figs. 263 and 264.) As the suture is drawn up and secured, 
the precaution is taken to draw up and place in position the 
ends of the sphincter, so that they may be firmly secured. The 
remaining sutures appose the denuded surface of the perineum. 






-* 



Fis:. 266. — Cleveland's Suture. 



Fig. 267. — Dudley's Operation with 
Interrupted Sutures. 



Outerbridge modifies Emmet's operation in that he uses but 
three sutures. The first, of medium-sized catgut, by means 
of a needle threaded with a carrier loop, is passed from the end 
of the central undenuded portion to the summit of the lateral 
denudation upon either side. It is throw^n over the pubes and 
a silver-wire suture is passed from the highest point of the 
denudation upon one labium ma jus beneath the whole wound 
across to the corresponding point upon the opposite side. (Fig. 
265.) The catgut suture is now tied and its ends are passed 



TRAUMATISMS. 



313 



downward to penetrate the skin upon each side one centimeter 
from the lowest point of the denudation. This suture tied, 
the silver wire is secured. The latter suture is removed upon 
the eighth day. 

Cleveland uses a figure-of-8 suture of catgut. (Fig. 266.) 
The first suture enters the skin six millimeters from the wound 
margin and midway between the posterior commissure and the 
summit of the denudation in the left labium, passes deeply across 




Fig. 268. — Dudley's Operation Com- Fig. 269. 
pleted. 



-Denudation for Martin's 
Operation, 



between the denuded surface and rectum, embracing the muscles, 
and emerges upon the right labium six millimeters from the 
wound margin and, midway between the posterior commissure 
and the point corresponding to its entrance, is reintroduced at 
a similar point upon the left labium, and emerges upon the right, 
directly opposite its original entrance. 

The second suture follows a similar course. It enters the left 
labium near the summit of denudation, is buried beneath the 



314 



GYNECOLOGY. 



edge of the denudation to the center of the vaginal column, then 
passes downward, and emerges upon the right labium midway 
between the summit of denudation and the exit of the first suture. 
It is introduced upon the left labium at a corresponding point, 
passes across its former course, follows the border of the right 
sulcus, and emerges beneath the right summit. 

A suture of wire or silkworm-gut, for support, is passed 
through the left labium, about eight millimeters above the 





Fig. 270.— Vaginal Surfaces United 
Perineal Sutures in Place. 



ig. 271 



■Bischoff's Operation. 



denudation, and about the same in the anterior vagina and the 
right labium. 

A. P. Dudley made a quadrilateral denudation with angles 
at the summit of the rectocele, laterally at the caruncula, and 
at the posterior commissure. The denudation removes only the 
mucous layer, preserving the submucous. (Figs. 267 and 268.) 
The fino^er is introduced into the anus and the first suture is 



TRAUMATISMS. 



315 



passed downward and forward to the median line, where it is 
brought out, reintroduced three milHmeters from its exit, and 
carried upward and back^vard to emerge upon the other side 
of the vagina. This suture is tied, and acts as a fixed point from 
which to work. The remaining sutures, of juniper catgut, are 
made over and over and are introduced in a direction similar 
to the first, taking care to push up the rectocele with a director 




Fig. 272. — Splitting Vaginal Wall Preparatory to Sutnre.— {Andrews.) 



as each stitch is tightened. As the outlet is approached the 
angle of the sutures is decreased, until, when abreast of the hymen, 
they are passed transversely. At this point the inside work is 
finished and the suture is made fast. A number of buried sutures 
are passed through the fibers of the separated central tendon. 
These extend to the extremity of the rent, Avhen, with a con- 
tinuous suture, they return to the point where the deep sutures 
began. After examination of the wound for bleeding points or 



316 



GYNECOLOGY. 



gaping of the surfaces the wound is dusted with iodoform, and 
is not disturbed for four days. 

Martin, in extensive relaxation of the pelvic floor, supple- 
ments the operation upon the vulvar outlet by a denudation of 
the lateral columns of the vagina, leaving a tongue-shaped, 
undenuded strip in the median line of the vagina. (Figs. 269 
and 270.) Each lateral denudation is obliterated by continuous 




Fig. 273. — Introduction of Suture in Retracted Flap. — {Andrews,) 



suture, after which the outlet is closed with transverse sutures. 
(Fig. 270.) 

Bischoff dissects up a flap from the posterior vaginal wall, 
which he utilizes in covering over the line of vaginal union. 
The perineal sutures are passed deeply beneath the flap. (Fig. 
271.) 

In the incomplete lacerations with relaxation of the pelvic 
floor the aim of the operative procedure is to take up the slack 
in the vaginal wall and restore the support to the pelvic 



TRAUMATISMS. 



317 



viscera. Andrews, of Chicago, does this by first dissecting a 
small triangle pointed below by a line drawn across the vagina 
between the carunculee myrtiformes and below by the muco- 
integumental border; second, at the outer angle of this triangle 
on each side a finger is pushed beneath the mucous membrane 
to just beneath the cervix. This line is incised on each side, 
permitting the central flap to contract (Figs. 272, 273, 274); 
third, from the side of the cervix a suture is introduced through 




Fig. 274. — Suture Tied; the Remaining Surface to be Closed by Transverse 

Sutures. — {^''^drews.) 



the wall, carried as a submucous stitch around the central flap 
already designated, and tied. This folds the flap beneath and 
behind the cervix. This suture straightens or smooths out the 
posterior vaginal wall. The remaining portion is united by 
transverse sutures. Harris, of Chicago, seeks to utilize the 
puboperineal portion of the levator ani to hold the posterior 
segment of the vagina against the anterior by dissecting down 



318 



GYNECOLOGY. 



upon the muscle upon each side, excising a section, and uniting 
the cut surface. The fascia has been denuded over the posterior 
segment and sutures are at once inserted posterior to the re- 
tracted muscle. 

Flap Operations. — Tail's operation is the representative for the 
various flap operations. In incomplete tears the rectum is tam- 
poned with a sponge or with cotton or iodoform gauze covered 




Fig. 275. — Incision for Tait's Operation for Incomplete Laceration. 



with vaselin and furnished with a thread. While an assistant 
separates the vulva, two fingers are passed into the rectum, ren- 
dering the posterior wall tense. To form the flap, Tait uses 
pointed angular scissors. The point of one blade is inserted 
in the median line at the mucocutaneous junction, and the recto- 
vaginal septum is split to the depth of two centimeters, first 
to the left and then to the right, and is carried forward upon 



TRAUMATISMS. 



319 



each side to the point at which he wishes the posterior com- 
missure to be. (Figs. 275, 276, and 277.) This forms a semi- 
circle following the mucocutaneous junction. The flap is 
drawn up by tenacula and further separated to the required 
depth. On the borders the incision is carried deeply into the 
cellular tissue of the perineum and labium ma jus. Bleeding 
is controlled by forceps, and later by the pressure of the sutures. 






Fig. 276. — Line of Incision for Tait's 
Operation for Complete Lacera- 
tion. 



Fig. 277. — Appearance of Surface 
after Formation of Flaps. 



The sutures are passed with the fingers in the rectum as a guide. 
They pass transversely across the wound, the skin not being 
included. Four sutures are generally sufficient. The sutures are 
secured after the wound has been washed with sublimate solution 
(i : 1000) and the tampon has been removed. 

Sanger closes the skin edges with superficial sutures. 

In complete laceration the rectovaginal septum is split, form- 
ing a rectal and a vaginal flap, depending in extent upon the 



320 



GYNECOLOGY. 



depth of the tear. Sanger advises that it be made with the 
bistoury. These flaps are loosened at either extremity by pro- 
longing the incision upward just within the labia, and down- 
ward alongside the anus, thus forming a letter H, the trans- 
verse bar of which is formed by the split in the septum, and 
is at the lower part of the letter. These flaps, when separated, 
form a quadrilateral. Great care must be exercised in the 




Fig. 278. — Outline of Flap to be Turned Down to Form Raw Surface for 
Union. Flap thus Formed to Protect from Fecal Infection. — (Risttne.) 



introduction of the first suture, which must include the ends 
of the sphincter ani. 

Ristine, of Knoxville, Tenn., in complete laceration of the 
perineum, begins in the vagina and dissects a flap downward 
to the rectovaginal margin of the tear. This flap is made 
sufficiently long to insure its projection beyond the anus. The 
divided ends of the sphincter ani are exposed and united with 



TRAUMATISMS. 



321 



silkworm-gut sutures. (Figs. 278 and 279.) The flap is fastened 
over the Hne of union and serves to protect it from infection. 
This flap can be cHpped off at a later date after it has com- 
pletely served the purpose for which it was constructed. The 
same object is secured by Noble, of Atlanta, who loosens and 
draws down the anterior wall of the rectum. The tag of tissue 
thus formed subsequently contracts. 





I 



Fig. 279. — Flap Turned Down. 



Sphincter Closed and Sutures Introduced. 

— {Ristine.) 



Simpson's method is somewhat similar to Tait's in the manner 
of forming the flaps, but they are sutured separately, form- 
ing the anterior wall of the rectum and the posterior wall of 
the vagina, while the intervening funnel-shaped raw surface 
is united by sutures. (Figs. 280 and 281.) 

Frttsch's procedure still more closely resembles Tait's in 
the splitting of the flaps. (Figs. 282 and 283.) He detaches 



21 



322 



GYNECOLOGY. 



the rectum from the vagina, adds a lateral incision for the 
sphincter when its ends are retracted, and unites these with 
a provisional stitch, which serves during the operation to restore 
the shape of the orifice and to permit the accomplishment 
of reunion. He unites the rectum with catgut, using the Lauen- 
stein suture. The same suture is used to close the vagina, 




Fig. 280. — Outline for Simpson's Operation. 



and the perineum is completed by suture in superposed planes 
or by continuous catgut sutures in terraces. 

Alexander Duke, after introducing the left index-finger 
nearly its entire length into the rectum, with a double-edged 
bistoury penetrates the septum a distance of six centimeters; 
as the knife is withdrawn he enlarges the incision laterally 
to fiYQ centimeters. (Figs. 284, 285, and 286.) As the lateral 



TRAUMATISMS. 



323 



ends of the incision are pressed toward each other a lozenge- 
shaped opening appears. The sutures are introduced with a 
strong, sickle-shaped needle with eye in point, and silver wire is 
preferred for the suture. The needle is introduced just beyond 
the end of the incision, and, guided by the finger into the rectum, 
is made to encircle the incision, to be brought out beyond its 
opposite end. Drawing up this suture will give an idea of the 



% 




Fig. 281. — Sutures Introduced in Simpson's Operation. 

number of additional sutures required. The sutures secured, 
the distance betAveen the anus and the posterior commissure is 
considerably increased, with the formation of a thick perineal 
body. 

373. After-treatment. — Immediately after operation cleanse 
the vulva with alcohol and water, equal parts, dry and apply 
a sterile gauze pad which should be retained with a T-bandage. 
The nurse should be directed to sponge the parts with the same 



324 



GYNECOLOGY. 



solution, whenever soiled. The patient is unlikely to suffer 
pain, unless the laceration has been complete, when a suppository 
of opium extract, gr. j, and hyoscyamus extract, gr. ss , can 
be employed. The urine should be evacuated spontaneously 
and the parts subsequently sponged, as already advised. The 
position of the patient may be changed, but she should be 
discouraged from making severe efforts. In incomplete lacera- 
tions the diet will not require careful scrutiny, but in the com- 




Fig. 282. — Denudation for Fritsch's Operation. 



plete it should be limited during the first week to animal broths,, 
and subsequently for another week it should be restricted to^ 
articles that are easily digested. Secure an evacuation of the 
bowels upon the third day, and at least each alternate day 
subsequently. Exercise care that excessive purgation shall 
not occur. The sutures, if of silk or silkr^^orm-gut, can be 
removed in from eight days to two weeks. Catgut sutures 
need not be disturbed. Observe care in the removal of the 



TRAUMATISMS. 



325 



sutures; the patient is preferably placed upon her side before 
a good light, and an assistant gently separates the buttocks, 
exposes the ends of the sutures, and facilitates their withdrawal. 
Keep the patient in bed fully three weeks. After the fourth 
day the vagina may be irrigated once or twice daily with a 
disinfectant solution — sublimate (i : 2000) or formalin (i : 1500). 
Advise her to do but little walking for -a month, and interdict 
coition for two months. 





im 



&-^f 



Fig. 283. — Catgut Sutures for Union of 
the Rectal Wall. 



Fig. 284. 



-Incision for Duke's Op- 
eration. 



374. Choice of Operation. — It should be understood that 
no operation is applicable to every patient. The operation 
should be adapted to the special condition. In incomplete 
tears, without rectocele, the Simon-Hegar operation is satis- 
factory. In patients with rectocele, Emmet's or Dudley's 
operation will serve an excellent purpose. In cases of complete 
laceration, without much relaxation of the pelvic floor, no 



326 



GYNECOLOGY. 



procedure presents so many advantages as that described by 
Tait and modified by Sanger. If the tissues are redundant 




Fig. 285. — Incision Separated in Fig. 2 86. -^Incision United by Trans- 

Vertical Direction. verse Sutures. 

and there is need to afford support, the operation of Emmet 
for complete laceration is the most acceptable. 



INFLAMMATIONS. 

375. The recognition of the development of the genital tract 

from the coalescence of the Mullerian ducts makes it evident 
that it is a continuous canal Avhich must be especially vul- 
nerable to infection and its manifestation, inflammation. 
In experience it is rarely found that the alterations due 
to infection are confined to a single portion of this tract. It 
must be admitted, however, that the special structure of certain 
portions of the canal renders it more susceptible to the infiuence 
of special micro-organisms and their products. The cyhndric 
epithelium of the cervical canal is more vulnerable to gonorrheal 
infection than is the pavement epithelium lining the vagina. 
The recognition of the almost continuous uniformity with which 
the different parts of the canal become involved from the struc- 
ture primarily infected, and the frequent difficulty in isolating 
the primary site, have caused me to depart from the usual order 
in the consideration of this subject, and to discuss infection 
and the resulting inflammation as affecting the entire genito- 



INFLAMMATIONS. 327 

urinary tract, and subsequently to consider the features of its 
local manifestations. 

376. Micro-organisms as a Cause. — The most important ex- 
citing cause in the production of inflammation of the genito- 
urinary tract is the influence of micro-organisms. Inoculation of 
a mucous surface with a micro-organism may result in an imme- 
diate inflammatory reaction, which may subsequently extend to 
the neighboring structures by one of three ways: the mucous 
membrane, the lymphatics, or the blood-vessels. The original 
site of inoculation may be the vulva, vagina, utei^us, urethra, or 
the bladder sirrfaces, which are more or less exposed to external 
contact, or even the entire tract may be involved. 

377. Natural Protection against Infection. — The situation of 
the genital tract, the injuries to which it is exposed, and the 
opportunities for its infection by various germs render the com- 
paratively infrequent occurrence of inflammatory attacks sur- 
prising. The immunity against infection is to some degree 
secirred by the difference in the character of the uterine and 
vaginal secretions. It will be remembered that the uterine 
secretion is alkaline, while that of the vagina is acid; conse- 
quently micro-organisms which would readily flourish in the one 
canal are unfltted for the invasion of the other. 

378. How Immunity is Lost. — Any condition, then, which 
causes these secretions to be less antagonistic, or which leads 
the one greatly to preponderate, permits the activity of the 
germs and their products to become manifest. Lowered' vitality, 
exposure to cold, menstruation, the increased flow after par- 
turition or abortion, all render the secretion more alkaline and 
establish a more uniform soil for the development of micro- 
organisms. Apparently normal conditions may be overcome at 
once when the tract has been inoculated with some virulent 
poison. 

379. Inflammation and its Varieties. — Inflammation has been 
deflned as an expression of the eft'ort made by a given organism 
to rid itself of, or to render inert, noxious irritants arising from 
within or introduced from without. Inflammation may be acute 
or chronic, diftuse or circumscribed. It is denominated as acute 
when associated with pain, heat, burning, more or less swelling 
of the tissues, profuse discharge, and constitutional symptoms. 
Inflammation is chronic when the condition is somewhat pro- 
tracted ; the pain less severe or but slight ; the discharge less in 
amoimt and less irritating to the surrounding structure, and with 
but slight constitutional reaction. Diffuse inflammation may 
involve the entire genital tract, as in streptococcic or gonococcic 
infection, either of which may extend the entire length of the 
genital canal, involving vulva, vagina, uterus, and tubes, and 



328 GYNECOLOGY. 

even the ovaries, peritoneum, and cellular tissue. The last 
form of infection may simultaneously invade the urinary tract, 
but circumscribed or local irritation confined to a portion of the 
tract is much more common. 

380. The causes of inflammation should be divided into pre- 
disposing and exciting. The predisposing causes are those which 
produce congestion and disturbance of the normal equilibrium of 
the tract and, consequently, promote a favorable condition for 
the inception of infection. They may arise from disturbance 
of menstruation, involution, and traumatism. The first in- 
cludes the improper hygiene of menstruation, exposure to 
cold, fatigue, overexercise, and excessive sexual relation during 
the congestion immediately preceding or following menstruation. 
Not infrequently persons, to avoid the inconvenience of men- 
struation, will take a cold bath, with a view to its arrest. A 
prolific cause is neglect or imprudence following abortion, 
miscarriage, or parturition. The natural congestion consequent 
upon these periods is enhanced by exposure, which permits 
infection by various micro-organisms, with the resultant inter- 
ference of the normal physiologic results in inflammation and 
interference with the normal processes and the subsequent 
development of inflammatory changes. Uncleanliness or want of 
care upon the part of physician or nurse in a manipulation 
during or following labor or an abortion, or in the use of the 
uterine or vaginal douche; upon the part of the patient in 
handling the parts with unclean hands ; the act of masturbation 
or the employment of unclean instruments ; the retention within 
the uterus or vagina of portions of placenta, decidua, or blood- 
clots following abortion or labor ; the presence of foreign bodies, 
such as tampons, tents, stem pessaries, and especially soft- 
rubber pessaries, which are very prone to become foul, can 
properly be considered as causes. Traumatisms, including 
lacerations of the perineum, vagina, and cervix, from the un- 
skilful management of abortion or parturition, rough or unskilful 
examination, careless use of the sound or intra -uterine manipula- 
tion, without asepsis, and excessive or violent coition, are also 
contributing factors. Chefnic and vegetable poisons, such as 
phosphorus and the essential oils, may cause acute metritis. A 
patient suffering with chronic inflammation may have acute 
attacks which are excited by overexertion, sexual excess, opera- 
tions, or rough examinations. Inflammation may be promoted 
by the presence of uterine displacements, pelvic or uterine 
tumors, or profuse inflammatory exudates or morbid processes. 
The exciting causes are the pathogenic micro-organisms and 
their products. They are the gonococcus, the streptococcus 
pyogenes, the staphylococcus pyogenes aureus and albus, the 



INFLAMMATIONS. 329 

bacillus coli communis, the bacillus tuberculosis, and the sapro- 
phytes from the bladder, rectum, and colon. 

Inflammation of the vulva and vagina can be produced 
by the passage through them of a septic discharge from a slough- 
ing fibroid, by malignant disease of the cervix or uterine body, 
by the contents of a pelvic abscess or pus-tube, or by being con- 
stantly bathed with feces or urine escaping through fistula. 

Of the various exciting causes named, the most prolific is 
gonorrhea. In woman gonorrhea is far more dangerous than 
syphilis, for when infection once occurs, the entire genito- 
urinary "tract may become involved, and the individual sub- 
sequently suffers from chronic inflammation of the uterus, sup- 
puration of the tubes, inflammation of the peritoneum and 
ovaries, as well as cystitis, ureteritis, and inflammation of the 
pelves of the kidne3^s. She not only loses through its influence 
her power of reproduction, but develops inflammatory con-, 
ditions which, if they do not cause a fatal termination, pro- 
duce sucl\ destructive changes in the pelvic organs as to neces- 
sitate their removal in order to prolong life or render it endur- 
able. While the recurrence of gonorrhea may not in many 
cases cause sterilit}^ its existence renders the soil favorable for 
the development of sepsis subsequent to abortion, parturition, or 
rough and unskilful manipulation. Careless examination, the 
introduction of the sound, and other intra-uterine manipulation 
without thorough asepsis are too frequently the causes of ex- 
tension of serious pelvic inflammation. 

Acute exacerbations are readily produced by overexertion, 
fatigue, cold, or rough manipulation when the pelvic organs 
are the seat of chronic inflammation. 

381. Characteristics of Inflammation. — It should be well 
understood that inflammation, in the great majority of cases, 
is primarily a product of infection, and, consequently, is not 
necessarily to be regarded as a reprehensible process, but, on 
the contrar}^, as an effort to guard and preserve vital structures 
from injury and invasion. Its first aim, then, is defensive; 
the second, constructive and reparative. These processes are 
often so intermingled as to render differentiation difficult. 

The defensive element is more marked in the acute process, 
and is associated with proliferation, degeneration, and de- 
struction, dependent in degree upon the virulence of the in- 
fection and the capabilities of resistance. Efforts are set in opera- 
tion to establish a retaining wall. Blood stasis, cell proliferation, 
and exudation occur; degeneration and destruction follow. 
Such a process causes pain, a burning sensation, elevation of 
temperature, extreme sensitiveness, swelling, and more or 
less constitutional reaction. The process may terminate in 
resolution or go on to suppuration. 



330 GYNECOLOGY. 

Acute and chronic inflammation are ofttimes mere stages 
in the infective process, and the one insensibly fades into the 
other. In the latter, defensive action is slight and not marked 
by an extensive limiting wall. Naturally, the symptoms are 
less severe, and, as the constructive elements predominate, 
as seen in hyperplastic conditions, the neuropathic disturbances 
are more marked. 

The inflammatory process may begin with a chill, or with 
repeated rigors, associated with elevation of temperature and 
with tenderness over the pelvic organs, often so great as to 
render the contact of the clothing or bed-clothes quite unen- 
durable, especially when the peritoneum has become involved. 
Increased secretion and discharge is an invariable symptom, 
necessarily dependent upon the seat and character of the in- 
flammation. Disturbance of the functions of the genital organs 
also necessarily occurs. In acute attacks the organs are so 
sensitive that a digital examination is frequently attended 
with agonizing pain. 

The menses may be arrested (amenorrhea) or be greatly 
aggravated (menorrhagia), while not infrequently there is 
profuse irregular bleeding (metrorrhagia). Increased or ir- 
regular flow is more likely to be associated with involvement 
of the peritoneum and cellular tissues, because the resulting 
exudate obstructs the pelvic venous circulation. The bleeding 
occasionally is internal. More frequently, however, there is a 
transudation of serum and plasma into the cellular tissues, which 
forms the condition known as parametritis or pelvic cellulitis. 

382. Classification of Inflammation. — Frequently inflam- 
mation will begin in one portion and rapidly involve the struc- 
tures of the entire genito-urinary tract; therefore it is diflicult 
to specify any particular organ as its primary site. Further- 
more, in other cases the virulence of the micro-organisms may 
be so great and the defensive power of the patient so slight 
that general infection takes place, and localization, if it occurs, 
may be in organs remote from the site of original infection. 
The gonococcus is an example of the former, while infection 
with the streptococcus illustrates the latter. In the majority 
of cases inflammation preponderates in a portion of the genital 
canal or pelvic structure, and is named for the part mostly 
affected. 

Inflammation of the vulva, vulvitis. 

" " ducts and glands of Bartholin, Bartholinitis 

" " urethra, urethritis. 

" ** bladder, cystitis. 

" " vagina, vaginitis. 

■' uterus, metritis. 

tubes, salpingitis. 

" ovaries ovaritis or oophoritis 



INFLAMMATIONS. 331 

A still more minute classification of inflammation is made 
in relation to the particular structure or portion of the organ 
involved, as the mucous membrane, the muscular structure, 
or the periphery. Thus, with the vagina we may have an 
endo vaginitis, a parenchymatous vaginitis, and a peripheral 
or perivaginitis. The uterus furnishes an endometritis, a 
parenchymatous metritis, a perimetritis, the last involving 
the peritoneal covering, and an inflammation of the cellular 
tissue, known as parametritis or, better, pelvic cellulitis. The 
tube is aff'ected by endosalpingitis, parenchymatous salpingitis, 
and perisalpingitis. Inflammation of the serous covering of 
the uterus, as announced, is called perimetritis. It is, however, 
rare to find this portion of the peritoneum alone involved. 
More frequently, the entire pelvic peritoneum, including that 
of the uterus, broad ligaments, and tubes, is inflamed, so that 
the term pelvic peritonitis affords a more accurate description. 
Inflammation of the pelvic peritoneum rarely occurs without 
more or less inflammation of the cellular tissue. It can not 
be denied that we may have cellular inflammation without 
very extensive involvement of the enveloping peritoneum. 
When this occurs, it is known as pelvic cellulitis. 

383. Vulvitis and its Varieties. — Inflammation of the vulva 
varies in degree from a slight erythema to a very severe and 
destructive involvement which may result in the formation 
of an extensive abscess, or in the destruction of a large portion 
of the labium. It is usually divided into simple or catarrhal, 
follicular, venereal, eruptive, phlegmonous, and diphtheric. 

384. Causes. — Vulvitis is generally produced by infection. 
Its development is favored by neglect of cleanliness. The 
decomposition of the sebaceous and sudoriferous glandular secre- 
tion and of the smegma, which accumulates between the labia 
majora and labia minora and beneath the prepuce of the clitoris, 
will often cause an attack of inflammation similar to balanitis 
in the uncleanly male. In obese women the decomposing per- 
spiration, frequently associated with vaginal discharges, will keep 
the surfaces constantly irritated and produce an extremely 
offensive odor. 

The tendency to inflammation is enhanced by the gouty, 
rheumatic, and scrofulous diathesis, and by intemperance in 
eating and drinking, especially the latter. Vulvitis is often 
produced by uterine and vaginal discharge, from malignant 
disease or from discharging abscesses. 

The continual soiling of the vulva with the urinary and 
fecal discharge associated with fistula is productive of vulvar 
inflammation and often erosion of the surfaces. Vulvitis 
is excited and aggravated by masturbation and excessive 



332 GYNECOLOGY. 

coition, from the pruritus occasioned by the presence of pin- 
worms, ants, and pedicuH. The various eruptive diseases, 
as eczema, herpes, acne, furuncle, warts, and venereal sores, 
are productive causes. A severe form of vulvitis is generally 
associated with eczema, and intense pruritus is caused by 
the presence of the torulag cerevisiae in diabetic urine. Inspec- 
tion will reveal whitish tufts over the surface, which arise from 
the spores of the oidium albicans. Severe vulvitis with eczema 
should always lead to examination of the urine in order to 
exclude the presence of sugar. Vulvitis is a frequent complica- 
tion in the eruptive and infectious diseases of childhood, such 
as scarlatina and diphtheria. It may arise from the extension 
of inflammation from the anus or bladder. 

385. Vulvitis — Simple or Catarrhal. — In the acute stage 
of vulvitis the labia minora, the clitoris, and the fourchet are 
swollen and thickened. The parts are red, angry, and dry; 
later, they are covered with a profuse purulent discharge of 
an extremely offensive odor. This discharge is produced by 
an increased secretion of the sebaceous glands mixed with 
desquamated epithelium and pus-corpuscles. 

Pruritus, as in all forms of vulvar inflammation, is a marked 
symptom, and is at times so severe as to prevent sleeping and 
force the patient to abjure society. The temptation to scratch 
or rub the parts becomes almost irresistible. The contact 
of the urine causes smarting or burning. As the disease be- 
comes chronic, the surface is not so bright a red; it becomes 
abraded; at points, small ulcers form, the skin is greatly thick- 
ened, the papillse become hypertrophied, bleed easily, and are 
red; often the surface presents points of excoriation, which 
extend upon the vulva into the groins and the inside of the 
thighs, when the itching is intolerable. The glands in the 
groin often become swollen, and may even undergo suppuration. 

386. Follicular Vulvitis. — The follicular inflammation is 
limited to the hair-follicles or originates in the sudoriferous 
and sebaceous glands. (Fig. 287.) The surface of the vulva is 
studded with small round protuberances the size of a millet-seed 
or hemp-seed. These elevations begin as papules, which may 
suppurate, forming pustules, which burst and shrivel, or they 
may remain as small indurations. The intervening skin is 
unaffected. 

387. Venereal Vulvitis. — Venereal inflammation of the vulva 
is produced by gonorrhea, syphilis, and chancroid. The former 
is the most prolific source. Gonorrheal vulvitis is much more 
intense than the catarrhal. It particularly involves the ves- 
tibule and smaller labia. The latter are very red and ede- 
matous, while the external meatus of the urethra and the ori- 



INFLAMMATIONS. 



333 



fices of the ducts of Bartholin are generally red and swollen. 
Small excoriations frequently occur which bleed easily. The 
disease is attended with a very profuse purulent secretion, in 
which the gonococcus is found. The microscope shows the 
subepithelial tissue exceedingly vascular and infiltrated with 
solid groups of round cells. The epithelium will be seen in 
varying stages of granular degeneration and desquamation. 
Gonococci penetrate the epithelium and are found in the under- 
lying tissues. The inflammation extends to the vagina, not 




Fig. 287. — Follicular Vulvitis. 



infrequently through the urethra to the bladder, and often 
Bartholin's glands are inflamed, occasionally resulting in abscess 
formation. Llicturition is followed by intense burning. Vul- 
vitis due to syphilis occurs in the form of a single sore with 
indurated base and excavated surface, which is situated upon 
the large or small labium or in the neighborhood of the clitoris. 
In the secondary stage there are mucous patches similar to 



334 GYNECOLOGY. 

those found in the mouth. Chancroids produce a more or 
less extensive ulceration, generally involving adjoining sur- 
faces; syphilis causes indurated enlargement of the inguinal 
lymphatic glands, while chancroid is characterized by their 
inflammation and suppuration, causing the condition known as 
buboes. 

388. Eruptive Diseases of the Vulva.— Skin diseases mani- 
fest the same characteristics when situated upon the vulva 
as in other portions of the body. The most important, be- 
cause the most frequent, are eczema, erysipelas, and herpes. 

Eczema generally begins upon the labium majus or upon 
the mons veneris, from which it extends to the thighs, peri- 
neum, anus, and over the buttocks. In the acute stage the 
surface becomes red and swollen, burns, and is covered with 
transparent vesicles the size - of a pinhead. It is associated 
with fever, gastric irritation, and rheumatic symptoms, and 
becomes chronic by the end of the second week. Chronic 
eczema generally appears in the form of eczema rubrum, and 
the surface is covered with pus, dry scales, or crusts. Fissures 
form at the fourchet and anus and in the genitocrural folds. 
All the symptoms are greatly aggravated at the menstrual 
periods. Pruritus is intolerable. The occurrence of eczema 
of the vulva is generally associated with the appearance of 
the disease upon other parts of the body. It is a frequent 
consequence of diabetes mellitus, owing to the irritation of 
the sugar-containing urine. It is also an outcome of the rheu- 
matic diathesis. 

Erysipelas may occur as a primary affection of the vulva 
in the new-born, when it is a very serious disease, frequently 
proving fatal. It occasionally occurs periodically with the 
catamenia, or may even take the place of the latter. Its oc- 
currence during the puerperal state is generally an indication 
of serious infection. 

Herpes manifests itself by the appearance of small trans- 
parent vesicles, from the size of a pinhead to that of a pea, 
which may be few or multiple, discrete or confluent; rarely, 
as a single erosion of large extent. The advent of the disease 
is characterized by heat, smarting, and an area of redness, 
which is covered with agminated vesicles. These vesicles 
may fuse and form a large bulla. The vesicles dry; the edges 
of an ulcer are scalloped and its surface is covered with a crust, 
beneath which cicatrization is completed within from eight 
to fifteen days. The inguinal glands are engorged and pain- 
ful, but do not suppurate. 

Causes. — Accidental herpes may be caused by syphilis, gonor- 
rhea, filth, and constitutional conditions. Congestion is a predis- 



INFLAMMATIONS. 335 

posing cause. In some women it occurs each month two days 
in advance of menstruation; also during pregnancy. 

389. Phlegmonous Vulvitis. — Phlegmonous inflammation of 
the tissues may result from the catarrhal or may be the result 
of violence. It affects the deeper structures and subcutaneous 
tissues, resulting in serpiginous ulceration, which may form a 
permanent fistulous tract, or the inflammatory area may be so 
extensive as to result in the formation of an abscess. 

390. Diphtheric Vulvitis. — Diphtheria may, but rarely does, 
affect the vulvar mucous membrane. The so-called diphtheric 
vulvitis is an exudation found upon lesions of the vulva and 
vagina, produced by parturition, and is the result of septic infec- 
tion. Such exudations are also found in grave constitutional 
disorders, such as scarlatina, smallpox, and typhoid fever. 

In a woman who succumbed to sepsis subsequent to the 
delivery of an intra -uterine sessile fibroid, whom I saw prior 
to death, the vulva, vagina, and uterus were lined with a diph- 
theric exudate. 

391. Diagnosis of Inflammatory Disease of the Vulva. — 
The diagnosis, especially the differential diagnosis, of the inflam- 
matory disorders of the vulva is of great practical' importance. 
Gonorrheal vulvitis is evident from the greater intensity of its 
symptoms. It is characterized by an increased burning dur- 
ing micturition, profuse purulent discharge, and redness of the 
meatus and oriflces of the ducts of Bartholin. It has a tendency 
to extend to the tubes, ovaries, and peritoneum, as well as an in- 
creased inclination to involve the urinary tract. Its recognition 
is rendered certain by the discovery of the gonococcus, and the 
known fact of exposure to the virus. The absence of the gono- 
coccus is not proof positive against the specific character of the 
disease, as the germ may have disappeared. Late investiga- 
tions seem to show that the gonococcus is capable of assuming 
amorphous forms and resuming its original form and virulence 
under irritation. Thus are explained the recurrences of the dis- 
ease after a debauch, excessive venery, or exposure to cold in 
individuals who are apparently cured. (For method of dis- 
covering the gonococcus see Section 90.) 

The production of vulvitis in the virgin by masturbation is 
suspected when the smaller labia and the space between them 
and the hymen are covered with small, pointed excrescences ; the 
nymphae are elongated; the clitoris or its prepuce is irritated; 
swelling of the shallow groove between the orifice of the urethra 
and the clitoris exists ; clear, abundant secretion from the ducts 
of Bartholin occurs ; and associated with these phenomena there 
is abnormal sensibility ; exaggerated prudery ; and distinct hysteric 
symptoms. Discontinuance of masturbation may be assumed 



336 GYNECOLOGY. 

when the hypertrophied nymphas become soft and no longer 
show any indication of inflammation. 

Eczema can be recognized by the similarity of its symptoms 
to those of the disease when it occurs in other portions of the 
body. Finding the cervix covered with whitish tufts should 
arouse suspicion of the presence of torula cerevisias, which is 
confirmed by the microscope and the discovery of sugar in the 
urine. It is a good plan carefully to examine the urine in every 
case of eczema of the vulva. Herpes is frequently confounded 
with chancroid, from which it is distinguished by its early his- 
tory. The formation of a vesicle is followed by its rupture, 
leaving a raw surface without a thickened inflammatory base 
and without loss of substance. The burning is more acute and 
the inflammatory symptoms subside more quickly. The lymph- 
atic glands of the groin -may become inflamed, but do not 
suppurate. The duration of herpes is from eight to fifteen days. 
In chancroid the sore has an uneven, fissured base, the edges 
of which are sharply defined, and its surface is covered with a 
greenish discharge. It presents points of abrasion, and generally 
the apposed surface becomes inoculated. Bubo develops in the 
groin. 

392. Treatment. — In all forms of vulvitis absolute cleanliness 
is essential. In the simple acute variety, absolute rest and the 
administration of salines are indicated. Tincture of aconite can 
be given in drop doses every one or two hours to decrease inflam- 
mation. In all varieties thorough local cleanliness must be 
observed. In the simple and follicular forms cleansing and 
isolation of the inflamed parts will frequently be sufficient to 
establish a cure. The cause of the inflammation, if possible, 
should be determined, and, when practicable, remedial measures 
should be directed to its removal. Vaginal discharge should be 
arrested, and the inflamed surfaces should be protected from its 
contact. The rheumatic, gouty, and scrofulous diatheses and 
improper habits must be corrected by proper hygienic and con- 
stitutional measures. The food should be carefully regulated 
and all stimulating and indigestible articles avoided. Alcohol 
in any form should be interdicted, excepting in the diphtheric 
and phlegmonous varieties. In the acute stages a bland diet or 
exclusive milk diet may be advisable. 

Catarrhal and Gonorrheal Vulvitis. — The treatment of these 
forms is of great importance, as in the latter infection may lurk 
in the diseased tissues for years. Cleanliness is secured by the 
employment of the hot sitz-bath several times daily, by anti- 
septic fomentations, such as gauze pads moistened with sub- 
limate solution, I : 2000 or i :iooo; carbolic acid, i : 20; boric 
solution, I : 50; equal parts of boric-acid solution, and of a solu- 



INFLAMMATIONS. 337 

tion of siibacetate of lead, or 5 per cent, solution of antipyrin, 
placed over the vulva and covered with oiled silk or rubber dam. 
In very acute conditions the distress will be much more quickly 
ameliorated by the application of lead-water and laudanum. This 
application may be kept cold by an ice-bag placed over it. These 
applications, whether antiseptic or emollient, should be frequently 
changed, the parts protected from vaginal discharge by a tampon, 
and the inflamed surfaces painted several times daily with a 
solution of Monsell's salt, i : 8, in glycerin or 20 to 40 per cent, 
solution of argyrol; on each alternate day silver nitrate, gr. x 
to the fluidounce, or compound tincture of iodin in water, i to 
2, should be used. Protargol, largin, argyrol, and argonin have 
been especially advocated as valuable in the gonorrheal form; 
alumnol in 2 per cent, solution has also been advocated. Ramon 
Guiteras highly recommends mercurol in 2 per cent, solution. 
These agents are more effective in the gonorrheal form. The 
sides of the vulva should be separated with absorbent cotton, 
surgeon's lint, or prepared cotton. After the subsidence of the 
more acute stage the surfaces should be dusted with zinc oxid, 
bismuth subnitrate, iodoform, boric acid and acetanilid in equal 
parts, lycopodium, starch, talcum, or one of the various combina- 
tions of these powders. Iodoform and tannin in equal parts are 
very efficient. Equal parts of alum and sugar afford relief in 
pruritus. Buboes and abscesses should be promptly incised 
and their cavities sterilized. In chronic vulvitis, astringents 
or caustics may be employed, the latter with the purpose of 
promoting sufficient metabolism to take up inflammatory ex- 
udate which has led to thickening of the tissues. Benzoated 
zinc ointment is a soothing application. The surfaces may be 
dusted with calomel or bismuth subgallate. Gonorrheal vulvitis 
is usually secondary. In chancroid the parts should be kept 
clean by frequent washing, the inflamed area isolated by gauze 
or lint, and drying powders should be employed, such as iodo- 
form, iodoform and tannic acid in equal parts, aristol and desic- 
cated alum, 4 to I , calomel and zinc oxid or bismuth subgallate 
and acetanilid. In herpes keep the surfaces clean and separated. 
Drying powders should be employed. 

In follicular vulvitis, in addition to strong antiseptics, alkaline' 
solutions are efficient. It may be necessary to shave the parts 
and to puncture and cauterize the individual follicles, or, in rare 
cases, to excise the affected surface. The ointment of ammoni- 
ated mercury, diachylon ointment, or ichthyol in lanolin (J-i 14) 
may be useful. Phlegmonous and diphtheric vulvitis require 
cleanliness, antiseptics, removal of sloughing tissue, and, in the 
latter, cauterization of the infected surfaces with strong carbolic 
acid. 

22 



338 GYNECOLOGY. 

Eczema, when acute, must be treated with emolHent appli- 
cations or starch poultices, and the surfaces should be carefully 
cleansed. The bowels should be regulated and constitutional 
measures employed for the correction of any disordered condi- 
tion. When eczema is associated with diabetes, compresses of 
hyposulphite of soda, half an ounce to the pint, should be kept 
in contact with the inflamed surfaces. In chronic eczema the 
parts should be thoroughly washed with strong potash soap and 
hot water. By this measure all crusts and scales are removed. 
Where the surfaces are too much irritated, cracked, and fissured 
for this plan of treatment, a starch or slippery-elm poultice may 
be applied. After thoroughly cleansing the surfaces, the apphca- 
tion of the following ointments will prove of value : 

H . Hydrarg. ammoniat., 3 ss 

Lanolin, 5 ij. M. 

Ft. ungt. 

H . Iodoform. , 5 j 

Zinc, oxid .^ ij 

Lanolin, 5iij. M. 

Ft. ungt. 

B . Acetanilid, 5 j 

Menthol, 3 ss 

Lanolin 5 j. M. 

Ft. ungt. 

Or diachylon ointment or one of the tar preparations may be 
employed. If the irritation is apparently kept up by a vaginal 
discharge, use a vaginal tampon. Laxatives should be given to 
regulate the bowels, and constitutional measures should be em- 
ployed for the correction of arthritic, scrofulous, or diabetic con- 
ditions, from any one of which the disease may have originated. 

393. Edema and Gangrene. — Edema of the vulva is fre- 
quently associated with pregnancy. It is common in ascites 
as a result of various obstructions of the circulation. It may 
follow labor and also result from varix of the external pudic 
vein. When one side of the vulva only is involved, infection 
should be suspected. Incisions of the vulva or spontaneous 
fissures permit the fluid to escape, but increase the danger 
of erysipelas, and may be followed by gangrene and slough- 
ing of the labia. The swelling in general anasarca is very 
great, and may render urination or the use of the catheter 
very difficult. 

A hard edema of one labium can occur from and persist 
after chancre. When it appears in the nymiphag or praeputii 
clitoridis, it resembles elephantiasis. The condition is known 
as syphilitic hypertrophy of the vulva. 

Gangrene of the vulva may be produced by traumatism, 
septicemia, and occur in weak and scrofulous infants. This 



INFLAMMATIONS. 



339 



form of gangrene in young children is known as noma. It 
is infectious, and presents a reddened, infiltrated labium and 
an ichorous discharge. A vesicle appears, which rapidly be- 
comes gangrenous. 

The treatment of edema is the same as that of the condition 
from which it arises. That of gangrene or noma consists in 
early excision, disinfection, and the exercise of measures to 
secure effectual nourishment. 

394. Bartholinitis {Inflammation of the Glands of Bartholin). 
— These glands — also known as the vulvovaginal, Duverney's, 
and Cowper's glands — are racemose glands the size of a bean, 
situated in the labia majora at the 
junction of the posterior and middle 
thirds. The duct, two centimeters 
in length, opens in front of the 
hymen, with an orifice the size of 
a pinhead. Catarrh of these glands 
is rare, but hypersecretion is not in- 
frequent. It is indicated by redness 
about the opening of the duct, which 
may be either dilated or closed, in 
the latter case forming a retention 
cyst. The secretion from these 
gland may be thrown off in par- 
oxysms, not infrequently in noc- 
turnal emission. The secretion is 
particularly discharged during erotic 
excitement. 

Inflammation can occur in either 
the gland or the duct. It is gener- 
ally due to specific infection, but 
may arise from streptococcic or 
staphylococcic forms. In very 
severe cases it is apt to be a mixed 
infection. It is most generally due, 

however, to gonorrhea. Gonorrheal inflammation having been 
lighted up in the gland, it may subsequently remain dormant, 
and afford material which may not only again infect the patient, 
but others coming in contact with the secretion. Inflammation, 
according to its virulence, may either produce a C3^st or result in 
the development of an abscess. Cysts are either single or multi- 
locular, ovoid, with a smooth surface, and seldom transparent; 
the contents are viscid and are colorless or yellow. From mix- 
ture with blood they may become chocolate colored. (Fig. 288.) 
The cyst varies in size from that of a nut to that of an egg, is gen- 
erally unilateral, and is most frequently situated on the left side, 




Fis:. 



Cyst of Bartholin's 
Gland. 



340 GYNECOLOGY. 

elongated in the axis of the greater Hp, and nearer the mucous sur- 
face. It seems elastic and compressible rather than fluctuating ; 
gives rise to discomfort in. walking and during coition, and can 
become inflamed and suppurate. Superficial cysts involving the 
duct may attain to the size of a nut ; they are usually situated 
at the base of the labium minus, and may project into the 
vagina beneath the mucous membrane. A cyst of the gland is 
deep, is generally larger, and is located behind the labium ma jus ; 
it elevates both labia and its duct is impermeable. 

The diagnosis is readily determined. In either solid or 
fluid tumors fluctuation is absent, and the transparency is 
insufficient. But when the diagnosis is doubtful, it can be 
ascertained by puncture. The conditions with which it may 
be confounded are: first, sacculated cysts of old hernial sacs; 
second, hydroceles in the canal of Nuck; third, a cyst in front 
of a hernia. From hernia, which may be an epiplocele, an 
enterocele, or ovarian, it is distinguished by the absence of 
succussion in coughing and by the determination of the con- 
nection of the mass with the abdomen. Hydrocele may fre- 
quently be displaced by pressure, is a larger tumor, gives more 
sensation of fluctuation, and is more translucent. Abscess 
may be secondary to the cyst or may originate from primary 
inflammation. Swelling and edema are marked over the pos- 
terior part of the vulva and about the anus, and the pain is 
acute and lancinating. The patient may have more or less 
fever; frequently, the urine is retained; fluctuation is distinct, 
and, if the abscess is not opened early, its contents may escape 
through several openings; pus is abundant and fetid. Fistulae 
may persist, and may result in a recto vulvar fistula, or a large 
ulcer may be present, associated with purulent secretion or a 
hypertrophic induration of the gland, with profuse discharge 
of milky, greenish pus. The gland is the last refuge of gonorrheal 
inflammation, and is a frequent source of unsuspected infection 
for men. It may be confused with anal abscess, phlegmon 
of the labium ma jus, or furuncles. In anal abscess there is 
more rectal disturbance, a more widely diffused inflammation, 
and the mass does not encroach to the same degree upon the 
labium. In phlegmon of the labium ma jus the inflammation 
is more external, and encroaches upon the cutaneous rather 
than upon the mucous surface. Furuncles are more sharply 
defined and present an indurated base. 

Treatment. — In early inflammation of the duct the pus may 
be evacuated by pressure and injected with a two per cent, 
sterile solution of ichthyol or a one per cent, solution of silver 
nitrate. The duct may be opened with a lacrimal knife, and 
a crayon of silver nitrate or a solution of zinc chlorid (i : 50) 



INFLAMMATIONS. 341 

may be introduced. In cysts, when the contents are evacuated 
by puncture, they quickly reappear. Obliteration of the cyst 
may be secured by injecting ten drops of a solution of zinc 
chlorid (i : lo) after the contents have been removed by as- 
piration, or the cyst may be incised and packed with iodo- 
form gauze. A preferable procedure would be extirpation. 
In order to overcome the difficulty of removing the cyst when 
collapsed, it may be punctured, emptied, irrigated with hot 
water, and injected with melted paraffin, and the latter hard- 
ened with ice, after which the mass thus formed is easily dis- 
sected. The wound produced by the removal of a cyst should 
be closed with sutures. In abscess early free incision at the junc- 
tion of the skin and mucous surface is important. To ex- 
tirpate the gland, wash the cavity with carbolic solution and 
pack with gauze. In fistula it may be wise to extirpate the 
gland, dissect out the fistulous track, and close the cavity with 
catgut sutures. 

395. Pruritus Vulvae. — Pruritus is a symptom of all forms 
of inflammation of the vulva. It results from the presence 
of pediculi, pin-worms, eczema, trichiasis; from hemorrhoids, 
disease of the kidneys, ureters, bladder, and urethra; from 
congestion of the pelvic organs and masturbation; and from 
acrid vaginal discharges. It is associated with pregnancy, 
menstruation, the menopause, old age, the gouty diathesis, 
and general nervousness. It is directly caused by lice, acrid 
discharges, and diabetes. In addition to the sources given, 
there is a form of pruritus in which the origin remains undeter- 
mined. This is designated as an idiopathic pruritus. It is, 
however, very questionable whether careful examination will 
not disclose a demonstrable cause of the disorder. Seeligman, 
in an investigation of a large number of cases, found in all a 
diplococcus which resembles the gonococcus in appearance, 
but differs from it in its process of growth, and, besides, it takes 
the Gram stain. 

Symptoms. — Pruritus produces intense itching, and, as a 
result of the scratching induced, excoriations are present, and 
the hair is often worn off the mons veneris. The patient avoids 
company, becomes melancholy, has loss of appetite and sleep 
and increased sexual desire, masturbation is excited, and she 
may become insane. Itching is continuous or occurs only 
at intervals it is increased by heat and is much worse at night 
or following any exertion. The relation of masturbation to 
pruritus is not always readily determined. The habit produces 
certain abnormal alterations as a result of the irritation: 
changes in the endometrium, glandular hypertrophy, ovarian 
irritation, increase of secretion, irritation and manipulation 



342 GYNECOLOGY. 

of the vulva. A bad circle is engendered; irritation causes 
masturbation, and this aggravates the inflammation. There 
are cases, however, in which most careful examination fails 
to disclose inflammation of the vulva as a source of the intense 
pruritus. These conditions are know^n as idiopathic pruritus, 
and are supposed to be due to nerve irritation. Such cases 
do not properly belong under the term inflammation of the 
vulva, but they are so rare, and the symptoms are so prominently 
associated with vulvitis, that their consideration seems more 
appropriate here. 

Prognosis. — The relief of the condition depends entirely 
upon its cause. In some cases it is exceedingly obstinate. 
The removal of the cause, as filth, pedicuh, or pin- worms, 
results in the removal of the disorder. The prognosis in mas- 
turbating alterations is by no means favorable. It may be 
exceedingly difficult to overcome the evil habit. 

Treatment. — The first aim in the treatment should be to 
discover and remove the cause. Upon the recognition of ped- 
iculi the parts should be shaved, and blue ointment should 
be applied. A strong sublimate solution, however, is the most 
eft'ective agent. The surfaces should be painted with a solu- 
tion containing one grain of corrosive sublimate to the ounce 
each of alcohol and water. Unless the parts are shaved, this 
application must be repeatedly made, for it is necessary to 
destroy not only the lice which are present, but also the spores. 
If the pruritus arises from the action of the ascarides scabiei 
(the itch insect), sulphur ointment or one consisting of thirty- 
five grains of betanaphthol in one ounce of vaselin are eflicient 
applications. Of course, in the latter condition, the application 
must be made to the entire body. 

The methods of treatment of eczema and vulvitis have 
already been given. When it is evident that the pruritus 
has been produced by pin-worms, the parts should be kept 
clean and the patient given fluidextract of senna and spigelia 
in half -ounce doses; a rectal injection of infusion of quassia, 
two ounces to the pint ; half a grain of sublimate to eight ounces 
of water; an injection of lime-water or a suppository of five 
grains of santonin, are also efficient measures. Hemorrhoids, 
glycosuria, and other causes should be recognized and treated. 
The diet is important. Alcohol and spiced food should be- 
excluded. The use of coffee will often cause severe pruritus. 
Milk is an excellent basis for the diet. The general health 
should be carefully considered. Tonics, such as arsenic and 
quinin, should be administered. When the patient is unable 
to rest, sleep should be secured by the administration of bro- 
mid of potash, 5j-5ij daily, or tincture of cannabis indica, gtt. 



INFLAMMATIONS. 343 

xx-xxv, thrice daily. When the measures just named are 
insufficient to secure sleep, sulphonal or trional should be 
given in preference to opium. Local vaginal injections of hot 
water; carbolized, sublimated, or borated cotton tampons; 
or fomentations of lead-water and laudanum can be employed, 
or a saturated solution of bromid of potash may be painted 
over the surface several times daih^ Local applications of 
chloroform in glycerin (i:8), hydrocyanic acid, two or three 
drops to the ounce, or a one per cent, solution of cocain may 
be used. A solution of carbolic acid, or a strong solution of 
silver nitrate, followed by cold compresses, may be employed. 
Seeligman advocates the use of an ointment containing lo 
per cent, of guaiacol in vaselin, and when this is not effective, 
it should be increased to 15 to 20 per cent. An ointment con- 
taining acetate of lead, chloral, camphor, or chloroform (a 
dram to the ounce), combined with vaselin, menthol, or a solid 
stick of nitrate of silver, is advised. The following formula may 
be employed : 

I^. Menthol, oss 

Lanolin, o j- M. 

Ft. ungt. 

In very obstinate cases the affected skin may be excised. Tam- 
pons containing equal parts of sulphurous acid and boroglycerid 
sometimes afford relief. The irritated surfaces may be painted 
with a solid stick of silver nitrate or a galvanic current can be 
employed. The employment of the :i:-rays has been advocated. 
The resort to tobacco smoking has afforded relief when all other 
means have failed. 

396. Kraurosis vulvae is an obscure form of disease, first rec- 
ognized by Breisky, which consists of an atrophy of the smaller 
labia. (Fig. 289.) The skin of the vulva undergoes essential 
changes. The capillaries of the corium become dilated, the rete 
mucosum gets thin and disappears, while there is a substitution 
of a thick horny layer of epithelium, which lies directly upon the 
corium. The papillse disappear, the undulating character of the 
skin is lost, and it becomes stiff and sclerosed,' with here and 
there points of small cell infiltration. As the disease progresses 
the sebaceous and sweat-glands are entirely destroyed. It is called 
chronic inflammatory hyperplasia of the connective tissue with 
inclination to cicatricial shrinking (Peter) . 

Mars divides kraurosis into tw^o stages: (i) The stage of 
edema, characterized by more or less inflammatory reaction; 
(2) the atrophy of elastic and connective-tissue skin layers 
with the formation of scar tissue; but Heller says it may be 
independent of the inflammatory process. He attributes it 
to some chemic irritation or a direct disease of the medullated 



344 



GYNECOLOGY. 



nerves, which leads to atrophy of the muscles, fat, and glands 
in the deeper layers of the skin, while a hypertrophic process, 
especially a hyperkeratosis, occurs in the superficial layer. 

Causes. — The cause is unknown. It has been attributed to 
gonorrhea and pruritus. A preceding inflammatory stage exists 
(Martin). Breisky found it more frequently in the pregnant; 
Martin and others, in the nonpregnant. 

Symptoms. — The surfaces become contracted, presenting a 




Fig. 289. — Kraurosis Vulvas. 

smooth, cicatricial appearance, devoid of glands, with reddened, 
inflamed points, not fully cicatrized. Pruritus is intense and 
causes severe burning and pain upon urination. The surface 
is dry, smooth, contracted, often flssured. The labia minora 
entirely disappear, and the clitoris becomes a mere papule. 
The vulvar orifice is contracted, and causes coition to be ex- 
ceedingly painful, often impossible. Childbirth results in exten- 
sive laceration. 



INFLAMMATIONS. 345 

Diagnosis. — The scratching of this disease should be sepa- 
rated from that of onanism and pruritus. The gratification 
induced by masturbation and the absence of cicatricial changes 
distinguish it. In pruritus the tears and superficial injuries 
are more marked and the disease is not so general, while in 
kraurosis the border of disease is more sharply defined toward 
the healthy skin. 

Prognosis. — Its spontaneous recovery is very doubtful. 
That carcinoma occasionally develops from it is exceedingly 
probable. 

Treatment. — The disease is exceedingly intractable to treat- 
ment. The application of cocain adds to the discomfort. Re- 
lief has been afforded by applications of strong carbolic acid, 
or of pledgets w^et with a solution of lead acetate. The thermo- 
cautery has been applied. The most effective treatment is 
the excision of the affected tissue, accomplishing union of the 
healthy tissue by sutures. Care must be exercised to prevent 
narrowing of the urethra. 

397. Vaginismus is a term employed to represent an abnor- 
mal hyperesthesia of the external genital organs which pro- 
duces muscular spasm. It is common in young, nervous, or 
hysteric women, and occasionally occurs without our being 
able to discover any source of irritation. Generally, a care- 
ful examination will disclose an irritable spot in the fossa navic- 
ularis; an inflamed and thickened hymen, which has failed to 
rupture, or, when it has ruptured, irritable carunculse myrti- 
formes; fissures in the fourchet or around the orifice of the 
vagina; small ulcerations Avithin the hymen; fissure of the 
anus; urethral caruncle or an irritable urethra. Nervous 
irritation of the vulva may be engendered by association with 
an impotent or partly impotent man. 

Symptoms. — Dyspareunia, or painful coition, and sterility 
are the m.ost marked symptoms. The slightest touch, or even 
the approach of the male, may cause powerful spasm of the 
sphincter vaginas muscle. I have seen similar spasm occur 
at every attempt at urination in a very hysterical woman. 
The suffering is so intense as to lead the patient at once to 
seek medical advice, or through a sense of delicacy she may 
endure the distress until it becomes intolerable. She becomes 
careworn, anxious, and even hysteric. The ordinary vaginal 
examination is often extremely painful. I have, however, 
observed patients in whom the pain seemed confined to the 
attempts at coition, and they apparently experienced no un- 
usual discomfort during a careful pelvic investigation. Be- 
fore attempting digital examination it is well carefully to in- 
spect the surfaces and to push the labia apart, when possibly 



346 GYNECOLOGY. 

the cause will be discovered. Hildebrandt has described a 
form of vaginismus due to spasm of the levator ani muscles, 
known as superior vaginismus, which is responsible for that 
unpleasant complication, penis captivus. It must not be over- 
looked that dyspareunia is occasioned by pathologic lesions 
of the floor of the pelvis, such as prolapsed, inflamed ovaries 
and tubes, inflammation of the cervix, pelvic cellulitis, or peri- 
tonitis. 

Prognosis as to cure is good. 

Treatment. — The first essential in treatment must be the 
removal of the cause. When the hymen is thickened and 
sensitive, it may be necessary to cut it completely away. Its 
mucous surfaces, however, should be sutured, in order to pre- 
clude the formation of cicatricial tissue. In irritable fissure 
the base should be divided, as in fissure of the anus, or touched 
with the thermocautery. Local applications are often effec- 
tive, of which one of the best is iodoform in powder or oint- 
ment. Its disagreeable odor, which often precludes its use, 
may be overcome by rubbing up a few drops of oil of eucalyptus 
with each ounce of the powder. Pledgets of cotton soaked 
in a four per cent, solution of chloral or in a two per cent, solu- 
tion of carbolic acid are useful. Ointments of opium, bella- 
donna, or ichth3^ol often afford relief. Neuromata, irritable 
carunculag myrtiformes, and urethral carunculas should be 
snipped off. In fissure of the neck of the bladder the urethra 
should be overstretched and cocain filaments or pencils should 
be used. In obstinate spasm glass dilators or plugs (see Fig. 
163) should be worn for an hour night and morning. The 
pain caused by the introduction of the plug soon ceases, and 
it can be decreased by anointing it with a medicated ointment. 
These instruments should gradually be increased in size. When 
the dilator can not be worn, recourse should be had to opera- 
tion. 

Sims divided the superficial fibers of the sphincter vagina — 
the bulbocavernosus muscle. With the patient anesthetized, 
two fingers of the left hand are passed into the vagina to stretch 
the ostium. An incision about two inches long is made on 
each side of the fourchet, extending from half an inch above 
the ostium to the raphe of the perineum. The ostium is thor- 
oughly plugged with gauze, which is kept in position by a T- 
bandage. This plugging is important to prevent hemorrhage. 
The gauze is removed the following day, after which the glass 
plug should be worn a portion of each day for several weeks. 

For incision, forcible stretching may be substituted. This 
is accomplished by introducing the thumbs (Tilt) or several 
fingers of each hand (Hegar) and forcibly separating them 



INFLAMMATIONS. 347 

until the muscular fibers yield under the traction. This pro- 
cedure affords the advantage that it is bloodless and that it 
leaves no granulating wound to cause a cicatrix. The gal- 
vanic current has proved beneficial. Constitutional treatment 
should always be combined with the local measures. Quinin, 
arsenic, and strychnin should be given. Outdoor exercise and 
change of scene should be encouraged and complete sexual rest 
enjoined. 

398. Vulvovaginitis is an inflammation of the vulva and 
vagina, most frequently found in young girls, and, in the great 
majority of cases, is believed to owe its origin to the presence 
of the gonococcus. Robinson,* in fifty-four cases of vulvitis 
in children, mostly under five years of age, was able to find 
cocci in the pus-cells which corresponded to the gonococci in 
forty-one. It may also be induced by want of cleanliness, 
by the decomposition of the natural secretions, and by the 
entrance of pin-worms where proper cleanliness after stool is 
neglected. The importance of the condition is too frequently 
underestimated. The infection can extend to the uterus and 
even pelvic peritoneum, producing changes which condemn the 
individual to suffering all her menstrual life and often render 
her sterile. The principal symptoms are pruritus, painful 
micturition, and a profuse yellowish, watery discharge, which 
constantly soils the clothing of the child, and keeps the vulva 
irritated. The intense pruritus may readily generate the habit 
of masturbation. 

The infection may be spread by the hands, towels, linen, 
and bath. In children's asylums it is not uncommon to find 
large numbers of girls thus affected. 

The condition is frequently complicated by ophthalmia, 
peritonitis, and arthritis. 

Treatment should be energetic. In the acute stage it con- 
sists in rest in bed, a light diet, and free evacuation of the bowels. 
The urine should be rendered bland, and cold applications 
should also be employed. Severe pain and burning can be 
obviated by local applications of cocain, several hot sitz-baths, 
and careful irrigation two or three times daily. 

In irrigation, cocain may be first applied. This can be 
followed by alkaline or antiseptic agents, potassium perman- 
ganate (i 14000 to I : 1000), silver nitrate (i : 2000), protargol 
(0.5 to I per cent.), or a ten per cent, solution of argyrol. The 
irrigation should be made through a soft -rubber catheter intro- 
duced into the vagina. If the vagina does not drain well, the 
hymen should be stretched, to remove any obstruction. After 

* "Trans.. Lond. Obst. Soc," Jan. 4, 1898. 



348 GYNECOLOGY. 

irrigation, the parts should be dried and a mild ointment applied. 
The vulva should be covered with a sterile dressing, which should 
be burned upon removal. The child and her attendant should 
be impressed with the danger of carrying the infection to the 
eyes. 

399. Vaginitis, elytritis, or colpitis is an inflammation of 
the mucous membrane of the vagina. The mucous membrane 
of the vagina closely resembles the structure of the skin, having 
few, if any, submucous glands. It consists of connective tissue 
surmounted by papillae covered with several layers of squa- 
mous epithelium. A longitudinal ridge is formed upon the 
anterior wall, from which rugas, or folds, like the teeth of a 
comb, extend upon each side. This formation is less distinct 
upon the posterior wall. The central projections are known 
as the anterior and posterior columns. The former generally 
terminate below in a rounded protuberance, called the vaginal 
tubercle, situated immediately above the meatus urinarius. 
Sometimes the anterior column is divided by a furrow into 
two portions. The rugae aid in promoting sexual excitement, 
and probably contribute to A^aginal enlargement during preg- 
nancy and parturition. They disappear toward the upper 
part of the canal. The vagina receives its blood-supply from 
the vaginal, uterine, internal pudic, and vesical arteries — 
branches of the anterior division of the internal iliac. The 
vagina is surrounded by a venous network or plexus, which 
communicates with those of the vulva, bladder, rectum, uterus, 
and broad ligament, and finally empties into the internal iliac 
veins. 

The lymphatics of the lower fourth communicate with 
the superficial lymphatic glands ; those of the upper three-fourths, 
with the internal iliac glands. 

The nerves are derived from the sympathetic, and form 
upon each side of the vagina a plexus which communicates 
with the inferior hypogastric. 

The arrangement of the epithelium and the absence of 
glands render the vagina much less vulnerable to infection 
than either the uterus or vulva. 

We have already referred to the normal secretions of the 
genital tract. Doderlein distinguished between the physio- 
logic and pathologic secretions of the vagina. The former 
is markedly acid, dependent upon the presence of a bacillus 
which produces lactic acid. The latter may be feebly acid, 
neutral, or alkaline, and contain a variety of micro-organisms — 
saprophytic and pathogenic. Probably fifty per cent, of preg- 
nant women have this pathologic secretion, in which germs 
flourish, and from which auto-infection is possible. The demon- 



INFLAMMATIONS. 349 

stration of the truth of this assertion greatly simplifies the 
study of the processes of infection. 

The vaginal discharge becomes alkaline during the menstrual 
period, during the puerperium, and in many cases of leukorrhea 
— a condition which is more favorable for the growth of micro- 
organisms and the infection of the genital tract. Doderlein's 
assertion, however, does not correspond with the results of 
the researches of i\lenge, Kronig, and Walthard. 

Kronig's investigations were confined to pregnant and 
puerperal women, and consequently are not a proper subject 
for consideration under gynecology further than to note his 
conclusion that the distinction between the physiologic and 
pathologic secretions is not determinable. He asserts that 
all secretions alike contain no pathogenic germs. All secre- 
tions are equally germicidal, though the vitality of the germ 
differs. It takes twice the time to kill the staphylococcus 
that it does to destroy the streptococcus. The vagina infected 
with germs will become aseptic in two or three days. The 
cause of this bactericidal power is as yet undetermined. It 
is not chemic, because it occurs whether the secretion is faintly 
or strongly acid; it is not believed to be due to a special bacillus, 
although some micro-organisms are known to be antagonistic 
to others. If it results from leukocytes, it must be due to a 
property independent of their contractile power, for the action 
continues after their subjection to a heat which would destroy 
the latter. The want of oxygen in the vagina will not explain 
it, for the staphylococci and streptococci are anaerobic — i. e.y 
grow independent of oxygen — and yet are killed. It is not 
mechanical, because particles of carbon and mercury are re- 
moved much more slowly. Possibly all these factors may 
unite to establish germicidal action. Kronig presents a very 
important practical observation, which is that a solution of 
corrosive sublimate for irrigation destroys the germicidal action, 
probably by precipitation of albumin, while plain water but 
lessens it. A necessary inference is that prophylactic injec- 
tions of corrosive sublimate are prejudicial when the secre- 
tion is normal. Alenge, in his investigations upon the non- 
puerperal, introduced pyogenic micro-organisms into the vagina 
in eight women, and found that the vagina cleansed itself from 
these organisms in periods varying from two and one-half 
hours to three days. The factors which compass this germi- 
cidal action are various forms of bacteria and their products, 
an acid secretion, possibly serum action, and the absence of 
oxygen. This activity is weak in infants, and is lessened by 
menstruation and by increased secretion from either the cervix 
or the bodv of the uterus, or even from the vaccina. It is de- 



350 GYNECOLOGY. 

creased when the vulva is patulous or the uterus prolapsed, 
and at the menopause. 

Walthard has directed attention to the influence of change 
of pabulum in restoring the lost virulence of micro-organisms. 
He inoculated the streptococcus into the ear of a rabbit with- 
out unfavorable results, unless the ear was ligated to lessen 
tissue resistance, when a streptococcus from the vagina became 
as virulent as those found in puerperal fever. It is possible 
that an innocuous streptococcus may thus be restored by the 
tissues during the puerperium, and similarly in gynecologic 
operations in which there is bruising of all the tissues, as in 
the enucleation of fibroids. 

400. Varieties. — Vaginitis may be divided into simple and 
specific (gonorrheal). The latter is exceedingly important 
because of its intractability and its tendency to extend. The 
distinction between acute and chronic is merely one of degree. 
Special varieties named are emphysematous, exfohative, dys- 
enteric, phlegmonous, diphtheric, and senile, but these are un- 
necessary distinctions. 

The etiology and pathology have undergone some con- 
sideration in our discussion of the action of micro-organisms. 
Of these, the gonococcus is most important, for upon its dis- 
covery will frequently depend the diagnosis. It was discovered 
and described by Neisser. The recognition of its presence 
in the secretion is diagnostic, but its absence can not be consid- 
ered a positive indication that the secretion is of other than 
gonorrheal origin. 

401. Pathology. — In simple vaginitis slight elevations of the 
mucous membrane occur, producing a granular surface. The 
granulations are produced by groups of papillae, which are 
infiltrated with small cells; as a consequence, the papillae swell 
up and push before them the stratified squamous epithelium. 
Superficial layers are shed. Later, the surface becomes more 
level, from thinning of the superficial covering. With the 
vaginitis of pregnancy not infrequently an emphysematous 
condition of the mucous membrane is associated. These ele- 
vations have been described as cysts containing a gaseous fluid. 
The gas consists of air and trimethylamin. Ruge says the 
gas is situated in the cellular tissue, Zweifel says the masses 
are vaginal glands the ducts of which have become closed. 
A similar condition has been observed following the climacteric. 
The exfoliative, dysenteric, or diphtheric vaginitis presents 
localized patches or an inflammation of the whole vagina. 
In the latter condition the mucous membrane becomes so swollen 
that it is with difficulty the finger can reach the cervix, which is 
also thickened and covered with an exudation. 



INFLAMMATIONS. 351 

Senile Vaginitis. — After the menopause the epithehal tissue 
is desquamated, the papilla atrophy, and the raw surfaces 
cause obhteration of a large portion of the vagina. It often 
causes curious constrictions of the upper vagina, rendering 
the canal frequently cone-shaped, with the small end above, 
which discloses the cervical opening as a mere dimple. Bands 
of contracting scar tissue are often seen, which divide the vagina 
into loculi. Desquamation of the epithelium occurs. This 
is probably produced by defective nutrition, and, later, granu- 
lations develop. A loss of elastic tissue also occurs, with an 
increase of connective tissue, which results in cicatricial con- 
traction. The same process can cause occlusion of the cervical 
canal subsequent to the menopause. 

Specific Vaginitis. — The most important cause of vaginal 
inflammation is gonorrheal infection. This produces an in- 
tractable form of vaginitis, which may continue for months, 
or even for years. It may extend over the mucous membrane 
of the uterus to the tubes, ovaries, and peritoneum, produc- 
ing endometritis, salpingitis, pyosalpinx, ovaritis, and pelvic 
peritonitis. 

402. Etiology. — Vaginitis is produced by gonorrheal infec- 
tion; irritating discharges from the uterus; the contents of 
perivaginal abscesses; the contact of urine or feces from fis- 
tula; vaginal injections, too hot or too cold, or those contain- 
ing injurious chemic agents; badly fitting pessaries; decom 
posing tampons; efforts to produce abortion or awkward at- 
tempts at sexual intercourse ; and the exanthemata ; and it may 
complicate typhus fever, smallpox, and scarlet fever. Diphtheric 
patches have been observed in a number of diseases, particularly 
in the puerperal state. Localized patches are seen in fistulas, 
in carcinoma, and about badly fitting pessaries. The disease 
is induced by the habits of the patient. The free use of alcohol 
produces the granular form of the disease. The gouty or rheu- 
matic diathesis is a predisposing cause. 

403. Symptoms. — Vaginitis is characterized by a sensation 
of burning, heat, and itching in the vagina; pain in the pelvic 
floor, increased by exercise; frequent desire to evacuate urine, 
with not infrequently scalding. A profuse mucopurulent leu- 
korrhea soon occurs. These symptoms are present in both 
the simple and specific varieties. In the latter the disease 
begins as an acute infection within from twenty-four to forty- 
eight hours after exposure, with itching of the urethral orifice, 
increased desire to urinate, a sensation of heat about the vulva, 
and burning and scalding upon passing urine. Generally, 
the tenderness and discharge are moderate ; occasionally, throb- 
bing is substituted. The distress is increased by walking, even 



352 GYNECOLOGY. 

by moving the limbs, and by the shghtest touch of the finger. 
The urethral orifice is reddened and slightly swollen, and a drop 
of thick mucus or mucopus can be pressed out. After one or 
two days the entire urethra is exquisitely tender, and the orifice 
is swollen, intensely red, and bathed abundantly with pus. 
Pus and blood can be extruded from the vagina by pressure 
over the urethra. The hymen, vestibule, and labia become 
swollen, edematous, and eroded, and are covered with pus 
and exudate. At the end of a week the acute symptoms have 
subsided, the discharge is abundant, and when the parts are 
neglected, they become eczematous and cause a disagreeable 
odor. The vulva may regain its normal appearance in two 
weeks, while the discharge may continue for three or four weeks, 
or even longer. Infection of the vaginal follicles and of the 
vulvovaginal glands is not infrequent. The inguinal lymphatics 
become swollen, and may even suppurate. In the early part 
of the attack the gonococci are present to the exclusion of all 
other forms of bacteria, but later they may entirely disappear. 
The disease shows a marked tendency to invade the deeper 
and more important organs by the continuous mucous mem- 
brane. 

404. Diagnosis. — Upon separation of the labia a profuse 
discharge is noticed, covering a reddened, thickened, and rough- 
ened or granular mucous membrane. The speculum reveals 
the vaginal mucous membrane as a red, swollen, smooth, velvety 
surface, from which the rugae have disappeared; or the redness, 
as well as the discharge, may be present only in patches. The 
cervix should be inspected, as the infection generally begins 
in it. The differential diagnosis between simple and specific 
vaginitis is often difficult. The history of a distinct infection 
would be valuable, but it is often too delicate a subject for 
interrogation. It may be suspected from the sudden onset 
of the attack, associated with urinary symptoms, a protracted 
course, and obstinate resistance to treatment. The inflamed 
urethra and ducts of the vestibule and the orifice of Bartholin's 
ducts, and not infrequently the formation of cysts or abscesses 
in the ducts or glands, with swelling of inguinal glands, afford 
additional confirmation. The recognition of the gonococcus 
by culture and microscopic investigation renders diagnosis 
certain. The absence of the gonococcus is not proof positive 
of nongonorrheal origin, for the gonococcus may disappear 
from the secretion. 

Even when the specific origin can be determined beyond 
peradventure, caution should be exercised in the expression 
of an opinion, as it may cause serious social unhappiness. The 
diagnosis of simple vaginitis will not be sufficient, but the 



INFLAMMATIONS. 353 

physician should carefully examine the various structures to 
determine, if possible, the exact cause. Pelvic abscesses dis- 
charging into the vagina have been mistaken for vaginitis. 

405. Prognosis. — The ease and rapidity with which vaginitis 
can be cured will depend upon the cause. The milder cases 
may be confined to the external genitalia, or may disappear 
even after the Fallopian tubes have become affected. In 
the more severe forms the entire genital tract may be rapidly 
involved, and portions of the tract may retain the disease and 
reinfect other portions. The general health is impaired in 
the chronic cases. The ovum, when it can enter, may find 
the uterus unfitted for its retention and, therefore, an abortion 
may result. Preexisting gonorrhea is said not to disturb the 
first two weeks of the puerperium, but subsequently there is 
a marked tendency for the germs to develop renewed virulence 
and to invade the healthy structure. 

406. Treatment. — When the disease is in its acute stage, 
the patient should be kept absolutely quiet in bed. Sexual 
activity should be suspended, as w^ell for the interests of the 
patient as for the prevention of further propagation of the 
disease. The diet should be confined to nonstimulating articles. 
Alcoholic stimulants, pepper, and various other condiments, 
should be prohibited. Saline laxatives are advisable, and 
the patient should be encouraged to drink largely of emollient, 
liquids or alkaline waters. 

Local applications should consist of hot sitz-baths, alkaline 
douches. A saturated solution of boric acid in hot water may be 
given for fifteen to twenty minutes out of every two or three 
hours during the day, and every four while the patient is re- 
cumbent at night. The ordinary fountain syringe serves well, 
or a piece of rubber tubing weighted at one end and provided 
with a clip and nozle at the other. The weighted end, with 
the coiled tube, is placed in a basin of water above the level 
of the bed, the clamp applied, and the end of the tube with- 
drawn and introduced into the vagina. The clip opened, the 
water is siphoned out as long as the external end is kept below 
the level of the basin. When the acute SA^mptoms have sub- 
sided, douches should be given every three hours for the first 
two weeks. These douches may consist of solutions of subli- 
mate I : 4000, potassium permanganate i : 4000, carbolic acid, 
lysol, or creolin, protargol 0.5 to i per cent., mercurol 2 per 
cent., sodium chlorid 2 per cent., or sodium bicarbonate 2 per 
cent. After the period mentioned the strength of the fluid 
may be doubled and the frequency of the applications is lessened, 
now employing them four times daily. The dry treatment 
consists in cleansing the surface with a douche or by washing 

23 



354 GYNECOLOGY. 

the vagina through a _ speculum ; dry and pack with borated 
or iodoform cotton, and repeat every eight hours until the se- 
cretion is checked, after which it is given twice daily. A 
dry absorbent dressing must be applied to the vagina every 
two hours. 

Astringent douches are substituted in chronic cases and 
after the subsidence of the acute stage. Cleanse and dry the 
vaginal walls and paint with silver nitrate solution (5j : f5J), 
■ followed by a tampon saturated with a solution of bismuth 
in glycerin, which keeps the walls separated. Fritsch recom- 
mends zinc chlorid (gr. ij : f.5J). A one per cent, solution of 
lead acetate, zinc sulphate or alum, potassium perman- 
ganate (i : 2000), or painting the surface with undiluted 
tincture of iodin, are serviceable. Acceptable powders are 
equal parts of tannin and iodoform, bismuth subnitrate and 
chalk, or boric acid and acetanilid of each equal parts re- 
tained with a tampon. In senile vaginitis cleanse with a satu- 
rated boric-acid solution. Tampons may be saturated with a 
0.5 per cent, solution of lead acetate, or strips of lint may be 
saturated in a five per cent, solution of carbolic acid in gly- 
cerin or smeared with zinc ointment. Vaginal suppositories 
of tannin and iodoform, each, five per cent. ; zinc oxid, ten per 
cent.; or lead acetate, two per cent., maybe employed. When 
the condition is very chronic, spray through a speculum with a 
two per cent, solution of silver nitrate. The spray drives the 
medicine into the crypts and folds, and is far more effective than 
swabbing. I have derived more benefit from tampons anointed 
with ichthyol in lanolin (i 14); it causes a desquamation of 
the entire epithelium of the vagina and is destructive to the 
gonococcus. 

407. Urethritis. — Inflammation of the urethra is an ex- 
ceedingly painful, but not an unusual, complication of pelvic 
abdominal procedures in which the catheter has been employed. 

Varieties. — It may be manifest as a simple hyperemia, an 
acute catarrhal urethritis, a chronic interstitial urethritis, or 
a granular or follicular urethritis. Associated with the ure- 
thral inflammation occasionally occur ulceration, fissures, and 
a sacculated condition of the urethra. 

408. Hyperemia may result from injury during a difficult 
labor; from uterine displacement and uterine growths affecting 
the pelvic circulation; from varicose veins, irregular urination, 
excessive coitus, or long-continued irritation. Probably the 
most frequent cause of hyperemia, which may continue until 
inflammation results, is the repeated use of the catheter. So 
probable is such a result that the majority of operators prefer, 
if possible, to have the patient evacuate the urine unaided. 



INFLAMMATIONS. 355 

When the employment of the catheter is necessary, the operator 
should have the nurse introduce the instrument for the first 
time in his presence, so that he can observe what precautions she 
employs and determine the ease with which she can accomplish 
the procedure. The instrument should never be introduced by 
touch, but always by sight. The vulva and the vestibule are 
generally covered with discharge, which may have decomposed 
and become infected by micro-organisms capable of producing 
serious discomfort when carried into the bladder. 

The labia minora should be separated and the vestibule 
sponged with absorbent cotton saturated with an antiseptic 
solution. The instrument, preferably of glass, should be per- 
fectly smooth, with no rough or cutting edges. It should be 
boiled, kept in an antiseptic solution, and previous to its use 
washed with sterile water. It is then anointed with carbolized 
vaselin and carried by gentle pressure upward and backward, 
without exercising any force. If the passage of the catheter 
is obstructed, withdraw and reintroduce it, as the instrument 
may have entered one of Skene's follicles. 

Even with the exercise of every precaution the urethra 
is often so irritated by the frequent introduction of the catheter 
that the patient may suffer more distress than from the con- 
dition for which the operation was performed; consequently 
whenever the patient can evacuate the bladder imaided, she 
should be encouraged to continue to do so, as the contact of 
healthy urine with a plastic wound, if the precaution is ob- 
served immediately to irrigate the latter, is less harmful than 
would be frequent catheterization. 

In operations upon the bladder Avhich require the urine to 
be frequently evacuated, a self -retaining catheter should be 
left in place several days. A soft-rubber instrument with 
a flange upon its vesical end is most serviceable. It can be 
plugged, permitting the urine to collect for two or three hours. 
It should not be permitted to remain longer than forty-eight 
hours without removal and careful cleansing. The ordinary 
glass catheter, with a long rubber tube attached, in my ex- 
perience, does equally well. 

409. Acute Catarrhal Urethritis. — The mucous membrane 
becomes thickened; its papilla are hypertrophied and are 
covered with an imperfectly developed epithelium. At points 
the latter is desquamated and the papillae are enlarged. This 
may result in the formation of a polypoid mass, which pro- 
jects from the surface frequently by a pedicle — the urethral 
caruncle. 

The acute disease may arise from long-continued and re- 
peated hyperemia or from traumatism, but it most frequently 



356 GYNECOLOGY. 

results from gonorrheal infection. The urethra is often the 
first point affected. 

Symptoms. — The onset of the acute attack is at first made 
known by itching or smarting of the urethral orifice, as the 
contact of the urine gives a sensation of a hot scalding liquid 
and urination is followed by intense burning along the course 
of the urethra. The meatus becomes red and swollen, then 
dark red and pouting. It is tender to the touch, and pressure 
along the urethra causes a few drops of mucopurulent or puru- 
lent secretion to be discharged. If the disease does not extend 
to the bladder, the symptoms soon subside or disappear. 

Diagnosis. — The condition should not be confounded with 
cystitis. Urination is not frequent. The pain and distress- 
are associated Avith micturition, Avhile in the intervals there is. 
comparative relief. The tenesmus of urethritis can be con- 
trolled ; it is attended with scalding, but is relieved by urination. 
In cystitis the tenesmus is uncontrollable, unrelieved by urina- 
tion, and there is no urethral burning. 

410. Chronic catarrhal urethritis is very generally an inter- 
stitial inflammation. The membrane is thickened and the 
canal narrowed, not infrequently permanently so, which results 
in a stricture. 

Symptoms. — Urination is frequent. Temporary retention 
of urine may, however, be caused by a spasmodic stricture. 
The latter is greatly aggravated by frequent coition or pro- 
longed exercise. The thickening of the urethra is apparent 
upon passing the finger down the anterior wall of the vagina 
along its course. A small sound can be passed through the 
urethra, while the introduction of a large one meets with re- 
sistance and produces severe pain. 

411. Follicular infiammation involves the follicles about 
the orifice of the urethra and Skene's glands. The latter are 
two tubules which will admit a No. i probe (French scale), 
and are situated in the floor of the female urethra, extending 
upward from the meatus about one or two centimeters. In 
the normal condition the orifices of the tubules are three milli- 
meters within the meatus, but with the urethra slightly pro- 
lapsed and the meatus everted, the orifices may be exposed 
to view. The upper ends of these canals terminate in a number 
of divisions, which project into the muscular wall of the urethra. 
(Fig. 290.) These tubules occasionally become so much enlarged 
as to permit the introduction of a small catheter. If such an instru- 
ment were forcibly introduced, it would tear through the tubule 
and establish a false passage. Such a passage might enter 
the urethra or pass beneath it into the tissue and thus enter 
the bladder. The follicles and tubules about the urethral 



INFLAMMATIONS. 



357 



3- 



ill 






orifice may become inflamed, with the consequent discharge 
of mucus and pus. The mucous membrane may become thick- 
ened or the orifices closed. The latter wil result in the formation 
of small cysts. 

Symptoms. — The symptoms are great tenderness ; discomfort 
in sitting, standing, or walking; dyspareunia; stinging pain; a 
sensation of heat; and frequent and painful micturition. The 
orifice of the meatus is partly everted, with red, puffy folds, 
which simulate caruncle, and with erosion of the labia minora 
and of the edge of the meatus. A few drops of purulent dis- 
charge can be extruded by pressure along the urethra. 

412. Ulceration is produced as a result of traumatism, from 
calculi, unskilful use of the catheter, specific 
infection, or the presence of the diphtheric 
or the venereal poison. 

During the passage of a calculus or 
while in labor, injury, laceration, or over- 
distention of the middle portion of the 
canal occurs, with contraction of the mea- 
tus. A small quantity of urine and mucus 
is retained, which decomposes, and results 
in the development of inflammation and 
in the production of a condition simulat- 
ing an abscess. 

Symptoms. — The most prominent symp- 
tom is dysuria, which becomes chronic. 
The meatus is large, of a deep-red color, 
granular appearance, and sensitive to pres- 
sure. The passage of an ordinary sound 
is readily accomplished, but is attended 
with pain. Sometimes a drop of blood 
is discharged. The sacculated form is 
associated with a copious discharge of pus, 
particularly when pressure is made along 

the urethra. Even when the discharge of urine is perfectly clear, 
pressure will cause a considerable discharge of pus. 

413. Vesico-urethral fissure holds an intermediary position 
between cystitis and urethritis, and strikingly resembles both. 
Its cause is undetermined. The fissure is situated at the in- 
ternal meatus, and resembles a crack in the lip or an ulcer 
similar to that which is found in fissure of the anus. The 
fissure is usually considered as being situated in the neck, but, 
as a rule, two-thirds of it is in the urethra. Only the upper 
end of it extends into the bladder. It may occur at any part of 
the circumference of the urethra, but, according to Skene, it 
is, in the majority of cases, situated upon the right side. In 



Fig. 



290. — Urethra Laid 
Open with Probes, 
Distending Skene's 
Glands. Posterior 
Wall Divided.— 
(Byford, after 
Skene.) 



358- GYNECOLOGY. 

length it is from six millimeters to one centimeter, and is from 
two millimeters to four millimeters in width at the widest part. 
It is deeper at either end. The deepest portion, yellowish- 
gray in color, resembles an indolent ulcer, while its edges are 
red and inflamed. Through an endoscope it looks like a fresh 
tear, the edges of which are abrupt, elevated, and indurated. 
Its situation explains the attendant discomfort. In any other 
portion of the urethra it produces little inconvenience beyond 
a smarting sensation, but at the junction of the bladder and 
urethra it is subject to constant though slight pressure, which 
causes severe and continuous pain. The portion of the fissure 
extending into the bladder is exposed to irritation from contact 
with the urine, producing a constant desire to urinate, a sen- 
sation of burning at the neck of the bladder, acute pain during 
and immediately following micturition, and severe tenesmus, 
causing the patient to continue straining efforts after empty- 
ing the bladder. The pain and burning immediately follow- 
ing micturition are often intense. Subsequently, it partly 
subsides, to return with the accumulation of a small quantity 
of urine. If the patient resists the inclination to urinate, the 
distress is greatly aggravated. 

414. Diagnosis of Urethral Inflammations. — The recognition 
of inflammation of the urethra is often difficult, because it is 
frequently complicated by inflammation of the bladder. Acute 
catarrhal inflammation of nonspecific origin usually begins 
gradually, and is often preceded by uterine or vesical symptoms, 
while the gonorrheal variety appears abruptly, and is preceded 
or attended by acute vaginitis or vulvitis. 

In both varieties urination is painful. Sharp scalding is pro- 
duced by urine passing over the inflamed surface, but the desire 
to urinate is not so frequent or urgent as in cystitis. Often the 
urine is long retained, for fear of the pain occasioned by its 
evacuation, or started with difficulty, because of the sensation 
of scalding as the urine passes over the inflamed surface. 

Slight hemorrhage is occasionally noticed, the urethral 
origin of which is evident from it being unmixed with urine, a 
few drops oozing from the external meatus subsequent to urina- 
tion. Urethral discharge is common, and, except just after 
urination, it can be extruded from the orifice by pressing upon 
the urethra from the vagina. Microscopic examination of 
the discharge may reveal the presence of gonococci, which 
determines the nature of the urethritis. Absence of this germ, 
however, is not positive proof against the gonorrheal origin. 
To exclude cystitis, introduce the catheter, allow some urine 
to escape to wash away the mucus introduced with the in- 
strument, and retain the remainder, which will be found free 



INFLAMMATIONS. 359 

from sediment. Pressure along the urethra from the vagina 
is painful in urethritis, while pressure over the bladder, unless 
complicated by cystitis, is not uncomfortable. 

In chronic urethritis the urethra is less sensitive, but it 
will be noticed as a somewhat thickened cord when examined 
from the vagina. 

In granular erosion the pain during micturition is excruciat- 
ing, it is associated and followed by tenesmus, and is more 
likely to be found in old persons. 

The character of the disease is assured by its history and 
by the appearance of the urethra. Fissure, urethritis, and 
cystitis are distinguished, the latter especially by examination 
of the urine. Fissure alone is free from all the products of 
cystitis. Urethritis is excluded and the fissure detected by 
the use of the endoscope. The endoscope is more satisfactory 
than the ordinary open instrument, because it exposes the sur- 
face of the fissure, which would be overlooked with the open 
end instrument. As a rule, the pain in fissure is more circum- 
scribed than in either urethritis or cystitis, and in many cases 
more acute. 

The maximum of pain in fissure follows urination, while 
in cystitis there is a sense of relief. In urethritis the most 
severe pain occurs during the act of urination. It then sub- 
sides slowly. 

415. Treatment of Urethral Inflammations. — In urethral 
hyperemia render the urine bland and unirritating by the 
exclusion of acids and stimulants from the diet and by the 
administration of saline cathartics. Relief is enhanced by 
giving ten grains of benzoate of ammonia or benzoate of sodium 
every three or four hours, and by the employment of hot hip- 
baths and hot vaginal douches. 

Acute urethritis, whether specific or otherwise, should be 
treated upon the same principles as in gonorrhea of the male. 
The treatment consists of constitutional and local measures. 
Internally, salicylic acid in ten-grain doses lessens the discharge. 
Salol, two grains every two hours with a glass of hot water, 
renders the urine bland and unirritating. Douche the urethra 
frequently with hot water through a reflux catheter (Fig. 291), 
so that the current flows back from a cap on the end of the 
instrument. Later, inject from one-half of one to one per cent, 
of carbolized water; sublimate, gr. -J^, to aq., f 5j ; silver nitrate, 
gr. I", to aq., f§j; or zinc chlorid, gr. x, to aq. f§j; preceded, 
when injection is painful, by the instillation of a solution of cocain 
with a pipet. 

In making urethral applications it should not be forgotten 
that the canal will hold but from ten to fifteen drops. If a 



360 GYNECOLOGY. 

larger quantity is thrown in by the pipet, it flows into the blad- 
der. A strong solution of silver nitrate (gr. x-xv to aq. fSj) may 
be applied by a pipet or applicator. The same quantity of a 
twenty per cent, solution of argyrol may be emplo3^ed frequently 
with very little discomfort and with very beneficial results. 

Internally may be administered those remedies which will 
have an inhibitory influence through the urine. These so- 
called blennorrhagic remedies are: copaiba, cubebs, sandal- 
wood oil, urotropin, and aminoform. 

The itching of subacute and chronic urethritis may be alle- 
viated by applications of different combinations of chloral or 
hydrocyanic acid, as in the following prescriptions : 

R . Chloral, J)iv 

Lanolin 5 j. M. 

Ft. ungt. 

R . Chloral, 

Camphor ^^ §.^- ^^^^ 

Lanolin 5 j. M. 

Ft. ungt. 

R . Acid, hydrocyan. dil 3 j 

Plumbi acet.^ gr. xv 

Glycerin f 5 j. M. 

These remedies may be brought in contact with the affected 
surface by the applicator. A suppository or bacillum of cocain 
in cacao-butter, or in combination with lead acetate, will give 
relief. These bacilla should be introduced into the urethra 
two or three times in the twenty-four hours, preferably after 
urinating. In prolonged chronic disease which has resulted 
in thickened walls and a more or less contracted canal, the 
dilatation of the urethra by bougies once or twice weekly will 
be beneficial. 

The bougie may be anointed for introduction with mercuric 
oleate, the official ointment of mercury, or any other medicinal 
agent which will have a beneficial influence upon the mucous 
surface. M. Julien, of Paris, applies ichthyol by dipping into 
it a cotton-wrapped probe, which is passed and repassed into 
the urethra several times. This agent has a destructive in- 
fluence upon the gonococcus. 

Granular erosion is best treated by brushing pure carbolic 
acid or silver nitrate (gr. xv to aq. fSj) over the surface. This 
should be repeated in eight or ten days. The urethra should 
be previously dilated. Following the subsidence of the acute 
symptoms, a few drops of a solution of zinc sulphate, gr. iv, 
fluidextract of hydrastis canadensis, f5J, aq., fSiij, may be used 
twice weekly with a pipet. Mercurol, 2 per cent, solution, has 
been found ver}^ serviceable. 



INFLAMMATIONS. 361 

In fissure, instillations and injections do harm by increas- 
ing the spasmodic contraction of the bladder, and they add 
greatly to the discomfort of the patient. 

A fissure may be exposed by a fenestrated speculum, and 
dusted with calomel, finely pulverized iodoform, or bismuth 
subnitrate, or the mitigated stick of sih^er nitrate may be em- 
ployed. Incision of the fissure, as performed in anal fissure, 
is successful. The urethra should have been previously dilated. 
Dilatation is one of the most effective methods of treating 
fissure. The precaution must be exercised, however, not to 
overdilate the urethra and thus produce permanent incon- 
tinence. 

Follicular tirethrtiis is most effectively treated by splitting 
up the tubes their entire length. This may be done with the 
thermocautery, or they mav be cauterized with carbolic acid 
and subsequently treated with milder agents, as in urethritis. 
In such cases, however, splitting up the canal is a prerequisite 
to cure. 

416. Cystitis is an inflammation of the mucous membrane 
of the bladder, and may be either acute or chronic. 




Fig. 291. — Reflux Catheter. 

Etiology. — The bladder is in intimate muscular relation 
with the uterus, as well as dependent upon the same nerve- 
centers and ganglia for its nervous distribution. A portion 
of the bladder lies in direct contact with the cervix, but in 
more close relation with the vagina. It is not surprising, then, 
with such intimate relations, that the condition of the bladder 
should be affected by disorders of the uterus. 

Inflammatory conditions of the bladder, if they have not 
originated from disorders of the uterus, are aggravated thereby. 
The symptoms of cystitis are more marked during menstruation 
and greatly aggravated by metritis. Vesical symptoms are 
engendered by uterine and vaginal displacements, b}^ subin- 
volution and hypertrophy, by tumors and pregnancy. The 
train of phenomena thus engendered may be enumerated as: 
difficulty in evacuation; retention and decomposition of the 
urine, producing irritation, and finally cystitis. Cystitis may 
be secondary to inflammation of the kidneys, ureters, or urethra. 
Chemic modifications of the urine mav result from indiscretions 



362. GYNECOLOGY. 

m diet, from the administration of irritating drugs, or from 
affections of the central nervous system. Inflammation is 
produced by traumatisms, injuries from the introduction of a 
catheter, or the presence within the bladder of a rough calculus. 

Without doubt, the most frequent cause of cystitis is in- 
fection. This may result from the deposition of bacteria by 
the blood, from the extension of inflammation from neighbor- 
ing organs, or the introduction of infection by way of the ure- 
thra. The infection is generally introduced into the bladder 
from the employment of the catheter. A violent form of cystitis 
is produced by retention of urine. A pregnant retrofiexed 
uterus which has become impacted in the pelvis, by pressure 
upon the neck of the bladder, not infrequently leads to gangrene 
and desquamation, or to separation en masse of the entire 
vesical mucous membrane. Neoplasms, such as cancer, tuber- 
culosis, polypi, and villous tumors, will usually excite a cystitis. 

Pathologic Changes. — The mucous membrane becomes in- 
jected, particularly about the orifices of the ureters and in- 
ternal meatus. As the inflammation progresses the entire 
mucous membrane is swollen and becomes a bright red. The 
epithelium is desquamated and patches of ulceration or hypertro- 
phied papillae appear, which bleed easily. Abscesses develop 
in the vesical wall. The micro-organism most frequently 
found is the bacillus coli communis. Disease is also induced 
by the staphylococcus, the gonococcus, and the bacillus tuber- 
culosis. 

417. Symptoms of Acute Cystitis. — Acute inflammation of 
the bladder is characterized by painful micturition; frequent 
desire to void urine, with only a few drops discharged at each 
attempt; severe vesical, and frequently rectal, tenesmus; a 
sensation of fullness or weight in the hypogastrium ; shooting 
pains in the perineum and anus; and a burning, lancinating 
pain, like a hot iron, in the urethra. These attacks may be 
almost continuous, or may, after a time, subside, to recur again 
in an hour or so. Examination by touch, whether over the 
abdomen or by the vagina or rectum, is extremely painful. 
The urine is scanty, highly colored, and becomes cloudy after 
standing. In very severe attacks the urine becomes a dark 
red color and contains blood and pus-corpuscles and uric-acid 
crystals. 

Constitutional disturbances are marked. These are nervous 
excitement, insomnia, and anorexia, followed by emaciation 
and loss of strength. Uncomplicated vesical inflammation 
does not cause elevation of temperature (Guyon). Partial 
or complete retention of urine is frequent. Paroxysmal pain 
results from vesical distention, and there may be frequent 



INFLAMMATIONS. 363 

evacuation or continuous dribbling of urine Avithout at any 
time emptying the bladder — an evidence of overflow known 
as the incontinence of retention. The course and duration 
of the disease are variable: it may subside in a few days or 
may continue alternately better and worse for weeks. 

418. Symptoms of Chronic Cystitis. — In chronic inflamma- 
tion the symptoms are less pronounced, though similar to 
those of the acute disease. Micturition is frequent and pain- 
ful, often difficult. The pain is pronounced at the beginning 
of the evacuation, thus leading to delay in starting. Exposure 
to cold, dampness, changes of clothing, indiscretions in diet, 
or constipation lead to acute or subacute attacks. The urine, 
after standing, becomes cloudy, and contains blood and pus- 
corpuscles, mucus, and uric-acid crystals. If drawn with the 
catheter, it is at first clear, then turbid, and toward the last 
pus is apparently discharged. The microscope reveals leu- 
kocytes, epithelial cells, tissue debris, and salt crystals. When 
the urine stands, it becomes alkaline, and bacteria in abundance 
are found. 

Constitutional Condition. — The patient is easily fatigued, 
has no appetite, loses flesh, develops a cachexia, has repeated 
inflammatory attacks associated with fever, repeated chills, 
a more or less continuous diarrhea, profuse sweating, and, 
finally, a fatal termination results. Such a train of symptoms 
and such a termination indicate the presence of an infectious 
pyelonephritis as a complication. 

419. Cystitis of gonorrheal origin is produced by the ex- 
tension of gonorrheal infection from the urethra, possibly 
through the careless employment of the catheter, but more 
frequently from the continuation of urethritis to the bladder. 
Its principal symptoms are frequent micturition, agonizing 
pain in the acute stages, associated with changes in the quality 
of the urine; hematuria is a constant symptom, but is rarely 
profuse. These symptoms do not occur in the early stage of 
the infection. The disease is then generally much milder, 
characterized only by tenesmus. In the mucopus of the urine, 
from the associated urethritis, the gonococcus may be found. 

420. Tubercular cystitis causes symptoms very similar to 
those produced by inflammation from gonorrhea and the irri- 
tation of calculi. Hematuria is a symptom in all varieties, 
but dift'ers in tuberculosis. It appears early in the disease, 
and the blood is generally mixed with the last drops of urine. 
The bleeding ceases as the disease advances. In common 
with other vesical inflammations, pain, urethral spasm, and 
retention and incontinence of urine are marked. 

421. Diagnosis of Cystitis. — Cystitis is not difficult to recog- 



364 GYNECOLOGY. 

nize. The frequent micturition, pain, alkaline reaction of the 
urine, large quantity of sediment, and mucopurulent appear- 
ance are ample evidence. In cystalgia and functional dis- 
eases of the bladder the urine will be found clear. Probably 
the greatest difficulty will be experienced in differentiating 
pyelonephrosis. Indeed, the infection from the kidney may 
lead to disease of the bladder and vice versd. The prognosis 
and method of treatment must depend upon the accurate 
determination of the structures involved. 

The existence of pyelonephrosis is recognized by finding 
the urine unaltered after irrigation of the bladder, while in 
cystitis it becomes clear. The condition of the urine from 
each kidney is recognized by securing the urine separately 
through catheterization of the ureters or by the employment 
of the Harris segregator. 

The careful investigation of the urine will often be sufficient 
to determine the diagnosis. Albumin is contained in the urine 
in either cystitis or pyelitis, but in very slight amount in the 
former, while it is present in quite large proportions in the latter. 

The presence of a proportionately great abundance of albu- 
min in the urine, associated with pus, should be considered 
as indicating the presence of renal disease. The most frequent 
cause is tuberculosis. The diagnosis of tuberculosis of the 
urinary tract is determined by the presence of the tubercle 
bacillus in the urine. Dr. Joseph Walsh, of Philadelphia, asso- 
ciated with Dr. Flick in his investigations in tuberculosis, 
however, informs me that the tubercle bacillus is found much 
more frequently in the urine of the tubercular patients than 
is generally supposed. The great majority of these patients 
will be found not to have a tuberculous kidney, though they 
will show a catarrhal condition of the kidneys, which is mani- 
fested by pains or aching in the bones, and by the presence 
in the urine of epithelial or granular casts, pus, and sometimes 
albumin. The bacilli may be found in the urine without any 
inflammatory symptoms. In sixty nonselected tuberculous 
patients whose urine Dr. AValsh examined, the bacilli were 
recognized in forty-four ; in thirty of these the disease was in an 
advanced stage; in ten it was considered marked, and in four, 
was only incipient. In patients in the advanced stages of 
the disease it is rarely that the bacilli will not be found in the 
urine. In five of the forty-four cases above cited tubercle 
bacilli were found in the urine, but not in the sputum, though 
the presence of a pulmonary lesion was recognizable. I have 
quoted Dr. Walsh fully, because his investigations seem to 
demonstrate that the presence of tubercle bacilli in the urine 
can not be accepted as evidence of the existence of a true renal 



INFLAMMATIONS. 365 

lesion. The usually recognized difficulty of finding the bacilli 
in the urine is my justification for quoting here Dr. Walsh's 
method of examination : * ' Six fiuidounces of urine are cen- 
trifugated in a water motor centrifuge ; the sediment is then 
poured on one or two cover-glasses and allowed to dry thoroughly 
(twenty-four to forty-eight hours). The process is complicated 
by an excess of the crystalline sediment, which may render it 
impossible to find the micro-organism. In such cases, there- 
fore, the sediment secured by centrifugation should be dis- 
solved in water, a weak nitric acid, or a caustic potash solution, 
and again subjected to the centrifuge. In rare cases the sedi- 
ment may resist any one or all of these solutions. After dry- 
ing, it is fixed to the cover-glass by passing the latter through 
a flame two or three times, repeating this procedure twice, 
at intervals of a minute or two. The procedure for determina- 
tion of the bacillus in urine requires more heat than the corre- 
sponding examination of the sputum. Even after the pro- 
cedure for fixing given, the sediment will occasionally be washed 
off by the running water and the specimen thus destroyed. 

' ' The specimen is stained with carbol-fuchsin for three to 
five minutes or longer, washed in turn with 95 per cent, and 
absolute alcohol for one to three minutes, decolorized, and 
counterstained with Gabbet's solution. The greater number 
of foreign elements in the urine, some of which hold the fuchsin, 
makes a larger experience necessary for the recognition of the 
bacilli than is requisite in sputum. 

* * The organisms must be absolutely typical to render the 
diagnosis certain." 

In examining over the abdomen of a patient suffering from 
tuberculous cystitis, greater pain is experienced by suddenly 
withdrawing the hand pressure than is produced by deep pal- 
pation. A cystoscopic exploration of the bladder will reveal 
the extent of involvement and amount of tissue destruction. 
Tuberculous cystitis may supervene upon the gonorrheal, 
without cessation of the latter. 

Primary vesical tuberculosis is manifested by a very ir- 
ritable bladder, frequent and painful micturition, followed by 
the passage of a few drops of blood. Such symptoms may 
subside, to be followed by an aggravated attack. The pres- 
ence of pus in the urine indicates preexisting disease, which 
may have been unsuspected. The progress of the disease is 
more rapid when complicated by the discharge of pus, the 
presence of a fistula, or the existence of pyelonephritis. Tlie 
last complication should be suspected when the urine shows 
the presence of a large pus sediment, inordinate quantities of 
albumin, and if the patient gives a history of incontinence of 



366 GYNECOLOGY. 

urine and repeated exacerbations of high temperature. Polyuria 
is a most constant symptom of urinary tuberculosis. 

Gonorrheal cystitis is associated with evidences of infection 
of other portions of the genito-urinary tract, particularly the 
urethra, glands of Bartholin, cervix, and pelvic organs, which 
have preceded the vesical disease. The gonococcus can generally 
be found. 

A form of inflammation of the bladder, known as mem- 
branous cystitis, is a condition in which there is more or less 
extensive exfoliation of the bladder-wall, as in pseudo- 
membranous, gangrenous, croupous, or diphtheric inflamma- 
tion. It is always secondary to overdistention of the bladder 
from retention of urine. The mucous membrane is anemic 
during distention, but upon the removal of the bladder contents 
it becomes acutely congested and engorged with blood. It 
may be produced by any obstruction of the urethra. The 
most frequent causes are incarceration of a retrofiexed gravid 
uterus, unilateral hematometra, fibroid and ovarian tumors 
deeply seated in the pelvis, and loss of muscle power in low 
fevers and in septic conditions. 

The nurse or attendant may be led by the incontinence 
to overlook the occasionally enormous distention. The en- 
largement is gradual, extending above the navel, in the form 
of a tumor, which may very readily be mistaken for an ovarian 
cyst. The distention reaches its maximum when the reservoir 
can retain no more, and the abdominal pressure produces an 
involuntary discharge of the overflow, a condition which has 
been spoken of as incontinence of retention. 

Even though the bedding is constantly soaked with urine, 
the bladder is never completely emptied. The continuous 
pain, involuntary discharge of urine, a suddenly formed, gradu- 
ally increasing tumor, percussion dulness over its site, absence 
of the uterus above the symphysis, and the projection backward 
of the anterior vaginal wall, should make plain the diagnosis. 
Constant dribbling of urine should ahvays awaken suspicion of 
such a condition. 

Catheterization of such a patient by an ignorant midwife 
may cause the formation of a false passage, or negligence in 
the previous cleansing of the vulva will favor the entrance 
of infective agents into the bladder. No more favorable con- 
ditions for the extension of the sepsis could be imagined. 

Even if cystitis did not exist, hyperemia, infection, and 
traumatism, as a result of retention, would not be surprising. 
The enormous distention of the bladder causes anemia of its 
mucous membrane, thus producing disturbance of nutrition 
and superficial necrosis. Deep necrosis is caused by bacterial 



INFLAMMATIONS. 367 

action. All such processes favor destruction of the mucous 
membrane. The inner wall of the bladder may become partially 
or completely detached, covered with phosphates of ammo- 
nium and magnesium, and penetrated with putrescent bacteria. 
The surface of the membrane is black or gray, contains numerous 
excavations, and sometimes horny concretions. The mucous 
membrane may come away in pieces or as a 'complete cast of 
the bladder. 

A portion of the membrane or the entire structure may 
lodge in front of the urethral orifice and completely obstruct 
the evacuation of urine. A small quantity of pus only may 
reward the introduction of the catheter. This pus has Accu- 
mulated at the lower portion of the bladder, but a more forcible 
pressure of the catheter may cause it to penetrate the mem- 
brane and permit the evacuation of the decomposing urine. 
Violent tenesmus is a frequent symptom of such conditions. 
The -urethra, dilated, will often permit the expulsion of the 
entire sac as a black, putrid mass. Cases have been reported 
in which complete exfoliation has taken place and the patient 
subsequently recovered good health without disturbance of the 
vesical functions. Neoplasms are differentiated from cystitis 
by the early appearance of hematuria, with absence of pain, 
tenesmus, or frequent micturition. 

The quantity of blood increases near the close of micturition ; 
it may continue for days or weeks, and may suddenly cease. 
Sometimes fragments of the growth may be discharged. Hema- 
turia dependent upon tumors varies with their character. If 
the growth is benign, its progress is slow, unless the pelvis of 
the kidney and ureters are involved. 

Cystitis due to the presence of foreign bodies, such as calculi, 
is characterized by severe pain, frequent micturition, violent 
expulsive efforts, and hematuria, after active exercise. In 
arriving at a correct diagnosis it must not be overlooked that 
very marked disturbance of the bladder may arise from the 
administration of various drugs, from the application of vesi- 
cants, especially cantharides. In such cases micturition is 
frequent and very painful, while tenesmus is marked. The 
withdrawal of the irritating cause is followed by prompt relief. 

422. The prognosis of cystitis is necessarily uncertain, and 
must depend upon the duration and character of the disease, 
extent of involvement, complications, and carefulness of treat- 
ment. When the disease has existed for a long time, the in- 
flammation has extended through the mucous surface, more 
or less involving the muscular coat and causing contraction 
and distortion of the organ. It can readily be understood. 



368 GYNECOLOGY. 

therefore, that no treatment will restore the functionating 
power of the organ. 

The prognosis is especially unfavorable when the disease 
has extended to the ureter, and especially to the pelvis of the 
kidney. Tubercular disease of the bladder also presents 
an unfavorable prospect for ultimate recovery, although I 
have seen most gratifying results when the tuberculosis was 
secondary to disease in one kidney and ureter after the removal 
of the offending organs. The favorable results in all cases 
will largely depend upon the carefulness of the treatment and 
the degree of cooperation the physician can secure from his 
patient. 

423. Treatment. — In the treatment of inflammation of the 
bladder the aim should be, first, to remove or lessen its cause; 
second, to afford relief to pain; third, to improve the general 
condition of the patient. 

Prophylaxis. — The first indication is met most completely 
by prophylaxis, which, in all conditions dependent upon microbic 
invasion, should be the first consideration. Disinfection of 
the body, of the surroundings, of the hands, and of the instru- 
ments is necessary. The old procedure of introducing the 
catheter by touch is reprehensible. In the puerperal woman 
artificial light may be necessary. The legs should be flexed 
strongly, the better to bring the vulva into view. A small 
vessel is placed between the limbs, or the patient may be placed 
upon a bed-pan, and a warm disinfectant fluid poured over 
the vulva, which may enable her to void the urine spontaneously. 
If unsuccessful, the vulva is sponged with a cotton tampon 
and an irrigation stream is directed upon the urethral orifice. 
Then the catheter is taken from a disinfecting fluid and care- 
fully introduced, to avoid pain. Occasionally there is resist- 
ance at the internal end of the urethra, which is not over- 
come without pain. Care should be exercised in the with- 
drawal of the instrument, as the mucous membrane may be 
sucked into the eyelet of the catheter. Pushing up the instru- 
ment before its withdrawal will loosen it, when it can be re- 
moved without vesical injury. Whenever possible, the use 
of the catheter should be avoided, as, notwithstanding all pre- 
cautions, the mucous membrane of the urethra will be irritated 
by its frequent introduction, thus affording an opportunity 
for infection. 

Medical treatment to a limited degree meets all the indications 
we have assigned for the treatment of cystitis. The acidity 
and tendency of the urine toward decomposition are combated 
by the use of diuretics and by the administration of large 
quantities of the alkaline waters, such as Saratoga, Vichy, 



INFLAMMATIONS. 369 

Seawright, Buffalo or Londonderry lithia, Carlsbad, or Seltzer. 
The salicylates are among the most efficacious remedies. Salol, 
2 to 3 grains, can be given every three or four hours ; strontium 
salicylate, 3 to 4 grains four times daily. Some of the formalin 
compounds have been found very effective, as urotropin, 5 to 10 
grains, four times daily. These drugs should be administered 
largely diluted. They prevent decomposition, remove the odor, 
and decrease the pain and tenesmus. They should not be 
given on an empty stomach. The diet, though nutritious, 
should exclude stimulants, acids, and condiments, except salt. 
Sugars and starches should be sparingly used, and in acute 
and severe cases it is well to restrict the patient to skimmed 
milk. In acute cases the patient should be confined to bed, 
and all exposure to dampness or cold should be avoided. In 
all cases care should be exercised regarding suitable clothing 
and protection against exposure. Pain may be so marked and 
micturition so frequent that measures must be instituted for 
its relief. Morphin or opium affords relief, but the pain soon 
returns. The remedy can not be repeated every two or three 
hours without danger of establishing the habit. An ice-bag over 
the bladder will frequently give comfort ; in other cases the hot- 
water bag is better borne. 

In the more distressing cases opium may be given in com- 
bination with belladonna or stramonium — tinctura opii deod., 
gtt. x-xv; tincture of belladonna, gtt. iij-v every two or 
three hours until relief; or suppositories of extract of opium, 
J- J of a grain, and extract of belladonna, |~^ of a grain, in 
cacao-butter — two, three, or four of these suppositories daily, 
according to the degree of pain. Relief is most quickly secured, 
however, by a hypodermatic injection of -I- of a grain of morphin 
with Y^Q- of a grain atropin sulphate. When opium is badly borne, 
cocain hydrochlorid, ^ of a grain, may be given in suppositories 
in combination with the same quantity of extract of hyoscyamus. 
When the pain is limited to the urethra, it may be delayed by 
injecting 30 minims of the two per cent, solution of cocain 
with 5 minims of solution (i : 1000) adrenalin chlorid through 
a syringe with bulb nozle. The openings about the bulb should 
be so situated as to direct the current back toward the external 
orifice. A celluloid is preferable to a metal syringe, because it 
can be used for sublimate and silver nitrate solutions. 

Inflammation of the neck of the bladder may be alleviated 
by the introduction, night and morning, of a vagina] tampon 
covered with an ointment containing 30 grains of extract of 
belladonna to i ounce of camphorated lanolin. 

Calculi and foreign bodies should be removed and shreds 

24 



370 



GYNECOLOGY. 



of membrane and casts of the bladder should be early separated 
and evacuated. 

Gonorrheal and acute cystitis are considered as requiring 
diuretics, such as the alkaline salts, alone or in combination 
with oil of birch, buchu, or triticum repens. The following 
prescription is often serviceable: 

R . Ammon, benzoat., ^iij — or 

Tinct. hyoscyami, f ,5 j-ij 

Ext. buchu vel tritici repens, ad f ,^ ij. M. 

SiG. — -A teaspoonful in an ounce of water four times daily. 

Marsh directs: 

B . Acid, oxalic. , • gr. xvj 

Syr. aurant. cort. , f 5 j 

Aq. pluv., ad f 5iv. M. 

SiG. — A teaspoonful every four hours. 

Benzoic acid, gr. x, in capsules may be given three or four 
times daily, directing the patient to take large draughts of some 
bland water. Benzoic acid, gr. x, or camphoric acid, gr. xv, may 
be given three or four times daily with great relief. 

The bromid salts are often of value. 
■ Free evacuation of the bowels by salines should be secured. 
After the severe distress and pain have subsided in acute cases 
and in all chronic inflammations advantage may be secured 
from intravesical medication. 

The bladder is irrigated through a return-current catheter 
by means of a fountain syringe: the fluid may be permitted 
to flow in until the discomfort is marked, when the tube is 
pinched and the fluid evacuated. (Fig. 292.) In the absence 
of a double catheter a single instrument may be used ; the bladder 
is filled and the fluid is allowed to flow out, and the process is re- 
peated until the bladder has been filled and emptied a number of 
times. This procedure, practised once or twice daily, gradually 
distends a contracted bladder and diminishes its irritability. 
The irrigation fluid may be hot normal salt solution; boric acid, 
3ij-iv, to water, Oij ; or methyl-blue (pyolctanin) , gr. xv, to 
water, Oiss, night and morning. If the urine contains pus, 
employ a 2 per cent, solution of ichthyol five or six times daily ; 
the strength may be gradually increased to five per cent, after 
subsidence of acute symptoms. The strength of the solution 
at the beginning should not exceed one-half of one per cent. 
S. D. Powell advocates irrigation of the bladder with a solution 
of carbolic acid i : 30, followed by irrigation with alcohol; 
subsequently a 2 per cent, solution of the carbolic acid is em- 
ployed. Protargol i to 10 per cent., mercurol 2 per cent, 
(zinc acetate and aluminol 1:4), are also highly extolled. 



INFLAMMATIONS. 371 

Lutaud advocates throwing into the bladder, after irrigation 
with a boric-acid solution, four ounces of tepid water, to which 
is added a teaspoonful of the following emulsion : 

Be . Iodoform. , 5 j 

Glycerin 3 x 

Aq. destil., ^v 

Tragacanth., gr. iv. M. 

This preparation should be introduced and permitted to 
remain. In necrotic and suppurative cases cleanliness is of 
prime importance. The bladder should be frequently irrigated. 
The frequent ichthyol irrigation is rapidly curative. Irrigation 
with 3 to 5 per cent, solutions of resorcin or with silver citrate 
(i : 8ooo to I : 4000) have been advocated. I have found great 
improvement following the injection of one to two drams of the 
10 to 20 per cent, solution of argyrol into the bladder and allow 
it to remain. In tuberculosis and chronic cystitis the daily in- 
jection of 15-25 minims of 5 to 20 per cent, solutions of guaiacol 
in sterile olive oil has been advised. The cavity of the bladder 
may be explored by dilating the urethra and introducing one 





Fig. 292. — Double-current Catheter. 

of the vesical tubular specula used by Kelly. With a good Hght 
the cavity can be carefully inspected and applications, such as 
silver nitrate, gr. x-xxx, to aq. destillat., f 5j, made directly to 
the affected area. In the use of these stronger applications 
touching the affected or ulcerated points with a solution should 
be followed by irrigation with a salt solution. 

In subacute and chronic cystitis Clark introduces a vesical 
balloon of thin rubber. This balloon is connected with a thicker 
rubber tube, provided with a cut-off valve. Before using, 
it is boiled in a boric-acid solution, and its surface is coated over 
with a mixture of gelatin and ichthyol, 10 per cent., or bis- 
muth and zinc, salicylic acid, or weak bichlorid. The mix- 
ture is melted and poured over the bag, which has been rolled 
in the shape of a suppository. With a slender pair of forceps 
the balloon is introduced through the speculum. It is then 
inflated by a bulb syringe, the number of bulb pressures re- 
quired to fill it having been previously determined. The balloon 
remains in situ twenty minutes. 



372 GYNECOLOGY. 

Guy on, in bad cases, advises that the bladder should be 
irrigated under anesthesia with a solution of boric acid or sub- 
limate (i : 10,000) and cureted with a medium-sized curet. 
The finger in the vagina as a guide enables him to go over the 
base and sides, while the hand over the abdomen aids in reach- 
ing the anterior surface; lastly, the urethra is scraped, the 
irrigation is repeated, and a self -retaining catheter is intro- 
duced and retained some fifteen or twenty days. 

Camero reports twenty-nine cases thus treated, of which 
nineteen were successful. Le Clerc-Dauday follows cureting 
by irrigation with a solution of chlorid of iron, and later by 
instillation of a i per cent, solution of silver nitrate. In serious 
tubercular cases in which pain and tenesmus are very marked 
cystotomy may be employed. It places the bladder absolutely 
at rest. A sound or bougie is passed through the urethra and 
used to depress the anterior vaginal wall, w^hile an incision is 
made through the septum. The vaginal and vesical surfaces 
are united by sutures to prevent the opening from closing. 
This procedure deprives the patient of control of the bladder 
contents, and requires the provision of an apparatus or receptacle 
for the urine. 

In septic conditions, where a large portion of the vesical 
mucosa has become necrotic, the removal of the gangrenous mass 
should be followed by irrigation of the bladder with a boric-acid 
solution (4 : 100) or a formalin solution (i : 5000). A graduated 
irrigator is preferably employed, and not more than three or four 
ounces should be injected at one time. This may be pressed out, 
and the fluid again allowed to flow in, repeating this twenty times. 
The irrigation should be performed four times daily. It is sur- 
prising in these cases of extensive septic inflammation to note 
the subsequent power to retain the urine. 

424. Ureteritis is inflammation of the ureter, and may be 
acute or chronic. It generally begins in the mucous mem- 
brane, extending through the wall of the canal, so that the 
ureter presents the palpable sensation of a thick, rigid cord. 

Causes. — The disease, according to Mann, is produced by 
a number of causes: first, injuries during parturition; second, 
from previous disease of the bladder; third, gonorrhea; fourth, 
suppuration in the pelvis of the kidney; fifth, pelvic disease, 
such as pelvic peritonitis, cellulitis, and tumors; sixth, abnormal 
conditions of the urine; seventh, tuberculosis, to which may 
be added an eighth — the passage of calculi. 

425. Acute ureteritis is often mistaken for intestinal colic, 
pain from renal strain, catarrhal appendicitis, or acute catarrhal 
salpingitis. The patient has a sudden attack of abdominal 
pain in which the distress is limited to, or more pronounced 



INFLAMMATIONS. 373 

Upon, one side, or but slight upon the other. The pain is in- 
termittent, with not infrequently severe paroxysms. General 
abdominal tenderness is probably absent, while there is notice- 
able tenderness upon deep palpation upon the affected side, 
which in the beginning is more marked near the pelvis of the 
kidney. The site of most marked tenderness may be situated 
at ]\IcBurney's point. As the inflammation subsides the pain 
disappears, and may be recognized at a point an inch above 
Poupart's ligament. Originating in the back, it can not be 
differentiated in the early stage from colic occasioned by renal 
strain. When complicated by intestinal disorder, it may be 
recognized by its characteristic progress from above down- 
ward, the appearance of vesico- ureteral tenderness, and the 
urinary disturbance. When occurring upon the right side, its 
symptoms are sometimes attributed to appendicitis. The con- 
dition may terminate in recovery or may result in the chronic 
form. 

426. Chronic ureteritis is characterized by frequent desire 
to urinate, which is more marked while erect, especially when 
standing, and is not wholly relieved by retaining the recumbent 
position. The patient is obliged to arise from one to many 
times a night; the discharge may or may not be painful. Fre- 
quently, the desire to evacuate the urine will be imperative, 
and the urine will gush forth before she can secure privacy. 
In some cases she complains of bearing down, greatly increased 
by standing, which disappears after a few hours' rest in bed. 
Palpation may afford no sign, except a slightly thickened cord, 
or a rigid mass almost the size of the finger, pressure along 
which will cause a discharge of urine with such power as to 
drive it some distance from the urethral orifice. The necessity 
for a cystoscopic examination of the bladder will depend upon 
the severity of the attack; when attended with much pain, 
it should be made. An alteration of the vesical mucous mem- 
brane in and about the orifice of the ureter will be recognized. 

This alteration may vary from a slight eversion and gaping 
of the orifice to one in which the orifice is an oval opening upon 
the summit of a mound of angry-looking mucous membrane. 
The mucous membrane in the immediate vicinity may be normal, 
but is generally red and injected, even roughened and eroded. 

The urea is said to be decreased upon the affected side. 

The urine may be secured for examination by catheterizing 
the ureters or by the introduction of the Harris double catheter. 

Treatment. — General treatment consists in the careful regu- 
lation of the diet, from which should be excluded strawberries, 
asparagus, and stimulants; tomatoes, onions, and cabbage should 
be used sparingly and with caution. The food should be largely 



374 GYNECOLOGY. 

albuminous, of which skimmed milk may often with advantage 
form its base. Large quantities of water, alkaline diuretics, 
or the alkaline waters are useful. In acute and subacute con- 
ditions the patient is best in bed. The nutrition should be 
maintained by general massage. 

Local applications are advantageously made to the inflamed 
orifice of the ureter and to the eroded surface about it. A 
solution of silver nitrate (gr. x-xxx to foj) produces good 
results. It should be applied through a speculum directly to 
the affected surface, after which the bladder should be irrigated 
with a normal salt solution. 

When the inflammation of the canal is extensive, the dis- 
ease may be treated by irrigation through a ureteral catheter. 

In tuberculous disease, which is generally secondary to 
disease of the kidney, the affected kidney (the other having 
been demonstrated to be healthy) should be extirpated, and 
with it the ureter. 



INFLAMMATION OF THE CERVIX AND BODY OF THE UTERUS. 

427. Classification. — The classification of uterine inflamma- 
tion has been and still is a difficult and perplexing problem. 

Various views have been presented. The existence of in- 
flammation of the endometrium, except in acute conditions, 
has been denied. The so-called chronic inflammation is de- 
nominated catarrh and uterine congestion, and is frequently 
attributed to peri-uterine inflammation. This statement would 
seem a distinction without a difference, and results from failure 
to appreciate the varying character of inflammatory changes 
in different tissues. The continuous mucous membrane is 
exceedingly vulnerable to the possibilities of infection. The irri- 
tation thus produced results in the production of inflammation. 
Its violence and extent will depend upon the virulence of the 
poison and upon the resistance of the patient. It may vary from 
a sHght inflammation which involves the cervix only to one which 
extends to the entire uterine cavity with infiltration of the sub- 
mucous structures ; may become interstitial or parenchymatous, 
and not infrequently in virulent attacks passes through the 
wall to its surface and causes perimetritis. In our early classi- 
fication we spoke of metritis, in a sense of inflammation of the 
entire organ; when it predominates in the lining membrane, it 
is called endometritis. When involvement of the deeper struc- 
tures occurs, it is known as parenchymatous or interstitial 
metritis, and as perimetritis if the peritoneum becomes involved. 
The latter condition is generally described as pelvic peritonitis, 
because, although inflammation can reach the peritoneum 



INFLAMMATIONS. 375 

as described, it more frequently does so by the progress of 
the inflammation through the tubes, and the inflammation ex- 
tends to other structures than those immediately enveloping the 
uterus. 

The anatomical arrangement of the cervical mucous mem- 
brane makes it evident why inflammation can be confined to the 
cervix, although in puerperal women it is very prone to extend 
to the body. 

The various classifications are based upon clinical phe- 
nomena, pathologic changes, and causal relations. The ideal 
classification is that of Doderlein, into two divisions: first, 
inflammation produced through the influence of micro-organisms ; 
second, inflammation independent of their influence. The 
former is subdivided into: (a) septic and saprophytic; (6) gon- 
orrheal; (c) tubercular; (d) syphilitic; {e) diphtheric. The 
brevity of our knowledge of the influence of micro-organisms 
makes a careful differentiation difficult, but we are scarcely 
in a position to assert that there is any inflammation that is 
absolutely independent of bacterial production. My experience 
as a teacher has led me to discard the classification based upon 
the clinical phenomena, because it is difficult to associate there- 
with the pathologic relations. For this reason I propose to 
present the simpler and more frequently employed classification 
into acute and chronic, the latter subdivided into cervical 
catarrh, or endocervicitis, endometritis, and metritis. Acute 
endometritis affects both body and cervix. The chronic in- 
flammation can be localized in the cervical mucous membrane. 
The classification of uterine diseases is still further complicated 
by the physiologic changes which occur in the uterus as a 
result of menstruation. Thus, the uterine mucosa undergoes 
a periodic hypertrophy and degeneration, and it is often difficult 
to differentiate between the physiologic condition and early 
pathologic processes. 

428. Endocervicitis — Ghronic Cervical Catarrh. — Cervical en- 
dometritis is an inflammatory process which aff'ects not only 
the cervical canal, but the entire cervix. The symptoms and 
appearance of the disease differ greatly in the unmarried or 
nulliparous and the multiparous woman, and it .manifests itself 
as inflammation of the portio vaginalis or of the cervical canal. 
In the former, the connective tissue of the vaginal portion of 
the cervix shows decided small-cell infiltration; the blood-vessels, 
especially the capillaries, become dilated and turgid with blood. 
Sometimes they become so distended as to form varicosities 
resembling hemorrhoids. Immediately beneath the epithelium 
the connective tissue is found rich in cells, Avhich later become 
converted into granular tissue. The squamous epithelium of 



376 GYNECOLOGY. 

the surface is in many places infiltrated with leukocytes, and 
it undergoes hypertrophic changes from the increased blood- 
supply. Numerous papillae are formed and become covered with 
a single layer of epithelium which permits the red color to show 
through and the surface to present the appearance of an erosion. 
(Fig. 293.) Such a condition is generally recognized as simple 
erosion, and it generally involves the squamous epithelium of the 
vaginal portion of the cervix. When the external os has been 
lacerated, the lips w^ll often be widely separated and gaping. 
The mucous membrane is everted and presents irregular granular 
patches which protrude beyond the os. Such a condition was 
formerly regarded as ulceration. The microscopic examination 





Fig. 293. — Simple Papillary Erosion Fig. 294. — Simple Papillary Erosion 

of the Cervix. with Enlarged Follicles. 

of such a surface reveals the apparently denuded portion covered 
with epithelium. The increased blood-supply and the infiltra- 
tion of the tissue with lymphoid cell cause the cervical lining 
to become everted and project from the os like a fungus. Such a 
reddened, everted surface is sometimes known as granular or pap- 
illary erosion. At first the glandular structure is not involved, 
but eventually hyperplasia of the glandular epithelium results 
and there is an increase in the number and size of the glands. 
(Fig. 294.) The latter condition is more hmited to the super- 
ficial structure, which seems to be taken up with glandular tissue, 
to the almost complete exclusion of the connective. In the 
former, the glands enlarge and project through the structure 
of the cervix, sometimes even lifting up the squamous layer. 



INFLAMMATIONS. 



377 



The accompanying hyperplasia of the connective tissue may 
cause more or less constriction of the gland-ducts, and in certain 
places they may be completely closed, thus resulting in the 
distention of the glands and the formation of cysts. These cysts 
are known as retention cysts or ovules of Naboth. (Figs. 294 and 
295.) They form nodular projections around the external os or 
can project deeply into the cervical tissue, becoming prominent 




Fig. 295. — Extensive Cystic Disease of the Cervix. 
Glands dilated with secretion, b. Large nodule formed by union of many 
glands and distended with fluid. 



Upon the vaginal surface at quite a distance from the external os. 
As the vaginal portion in the normal condition possesses no glands, 
it is evident these have been either extruded from the os with 
the hypertrophied mucous membrane, or have pushed through 
the structure of the cervix in the manner already described, 
and may lead to an extensive cystic degeneration of its structure. 
In one patient recently under observation change in the struc- 
ture of the cervix was so marked as to lead to the diagnosis of 



378 



GYNECOLOGY. 



sarcoma by myself and others, but the subsequent investigation 
disclosed that the condition was benign, though the cervix was 
entirely taken up with the cystic change. Infection may re- 
sult in the formation of abscesses, or the gradual distention 
may lead to a rupture of the cyst, producing what is known 
as follicular erosion, in which the greater portion of or the entire 
cervix may be involved. The increased glandular secretion, 
mixed with the transudation from the eroded surface, produces 
a very profuse leukorrheal discharge. The protruding struc- 
ture often is so extensive as to render its origin uncertain, but 
it evidently is produced by proliferation of the epithelial lining 













>^ 



Fig. 296. — Chronic Endocervicitis. 
a. Dilated gland forming cyst of Naboth. b. Detachment of glandular epi- 
thelium after absorption of fluid. 



of the cervical glands. Chronic inflammation of the connec- 
tive tissue occasionally causes such hyperplasia as greatly to 
increase the size of the cervix. In the nulliparous the cervix 
forms either a rounded mass, which increases the size of the 
cervix in all directions, or the latter may become so elongated 
as to produce a condition resembling prolapsus, and hence 
known as pseudoprolapsus. In previous laceration of the cer- 
vix only one lip may have undergone this hyperplasia, or both 
lips may be involved, when they will be widely everted and 
turned outward and baclavard, reminding one of the top of 
a celery stalk. The glands over such a surface are Hkely to 



INFLAMMATIONS. 379 

become obstructed and produce retention cysts, which are 
recognized as firm, pea-like masses beneath the finger. Occa- 
sionally such cysts form abscesses or rupture, and with the 
proliferating epithelium present an extensive raw surface which 
can be mistaken for carcinoma. A number of cysts in close 
approximation may become united through the absorption 
and breaking-down of the intervening septa and thus form 
one large cyst. Puncture of the cyst permits the escape of a 
large quantity of viscid fluid rich in corpuscles, with subse- 
quent contraction and obliteration of the cavity. 

From the discussion it can be readity inferred that the 
inflammation involves all the structures of the cervix, the epithe- 
lium, the glands, and the connective tissue, and thus varies in its 
form and manifestations according to the predominance of the 
structure involved. When the glands are extensively involved, 
the cervix presents what is known as cystic degeneration. The 
increase of connective tissue results in what Thomas has so aptly 
described as areolar hyperplasia or cervical sclerosis. 

429. Causes. — Inflammation of the cervix arises from exten- 
sion of inflammation from the body of the uterus, the vagina, 
and the vulva, as a result of excessive coition, laceration, in- 
juries during instrumental and digital examination and manipu- 
lation, and from puerperal and gonorrheal infection. The 
cylindrical lining of the cervix is particularly vulnerable to 
infection, especially after laceration, when exposed to friction 
against the walls of the vagina, and to injury during the act 
of coition or examination. It is rare to have inflammation 
of the body of the uterus without involvement of the cervix. 
The latter is prone to occur because the uterine discharges 
flow over the cervical mucous membrane and irritate it. Endo- 
cervicitis is particularly likely to be produced by congestion 
of the uterus in association with flexions, and especially retro- 
flexion. In retrodisplacements and in anteflexion separation of 
the lacerated surfaces is favored, and the delicate cervical mucous 
membrane is to a greater degree exposed. 

430. Symptoms. — The principal symptoms of cervical in- 
flammation are leukorrhea, pain in the back and loins, ag- 
gravated by exercise or standing, irregular menstruation, and 
sterility. Leukorrhea is the most important symptom. The 
normal secretion from these parts is insufficient to attract 
attention. When it is excessive, it becomes known as leu- 
korrhea, or, in popular language, the whites. A temporary 
discharge — a transparent leukorrhea, like white of egg — not 
infrequently occurs preceding and following the menstruation, 
due to temporary congestion. The secretion from the cervical 
glands is clear and viscid, resembling white of egg. It be- 



380 GYNECOLOGY. 

comes white when mixed with mucus-corpuscles, and yellowish 
when pus-corpuscles are present. Not infrequently it is tinged 
with blood, which escapes from the delicate vessels of the newly 
formed vascular tissue. Pain is aggravated by walking, stand- 
ing, riding, or anything which increases the friction between 
the cervix and the vaginal walls. i\Ienstruation is irregular 
and there is generally an increase in the quantity of the flow, 
probably produced by an extension of the inflammation to 
the endometrium. Sterility is often present. In the nullip- 
arous woman suffering from endometritis the cervical canal 
is filled by a plug of mucus, which may afford a bar to con- 
ception. In the multiparous woman the presence of cervical 
inflammation may render the woman less susceptible to preg- 
nancy, but it is not, however, considered an absolute obstacle 
to conception. 

431. Physical Signs. — The appearance and outline of the 
cervix differ in the nulliparous and in the multiparous woman. 
In the former it is puffy and large, the os being soft and velvety. 
The patient will complain of pain when the cervix is moved 
or pressed. In the multipara the cervix is generally lacerated; 
its margins are soft, velvety, and eroded, or hard, presenting pea- 
like nodules, polypoid projections, cystic masses; or the os may 
be gaping, so as to permit the introduction of the finger nearly 
to the internal os. The one lip may have undergone involu- 
tion, w^hile the other is enlarged and elongated. The mucous 
membrane is irregular, not infrequently presenting longitudinal 
ridges. Digital examination affords an idea as to the position 
and relation of the cervix, and as to its condition, w^hether lace- 
rated or otherwise. The digital examination should be supple- 
mented by the use of the speculum, the latter being used to con- 
firm suspicions which have been engendered by the digital exami- 
nation. The Sims speculum is preferable, as it aff'ords less dis- 
placement to the parts and permits more thorough and complete 
inspection. In the nullipara the os will be filled with a plug of 
tenacious mucus surrounded by a patch of excoriated tissue, par- 
ticularly upon the posterior lip, from which the outer layers of the 
epithelium have been desquamated. In the multipara a lacera- 
tion will probably be seen. Its presence is often overlooked, be- 
cause the fissures are filled up with indurated cicatricial tissue. 
The use of tenacula to turn in the surfaces demonstrates its 
existence. The bluish-red ovula Nabothi may be readily seen 
as nodular projections upon the surface. 

432. Diagnosis. — Cervical catarrh is readily determined from 
vaginal inflammation by the use of the speculum. In the 
former a plug of mucus will flll up the cervical canal and pro- 
ject from it, being so viscid and tenacious that its removal 



INFLAMMATIONS. 381 

is accomplished only with difficulty. To thoroughly remove the 
mucus from the surface it miay be necessary to use a curet. The 
mucus in the interior of the dilated glands should be removed 
by puncture and digital pressure. When the cervical dis- 
charge is insufficient to render it visible, Schultze's method 
may be employed. He gives the patient a vaginal douche, 
introduces a speculum, thoroughly cleanses the surface, and 
places a tampon soaked with a solution of tannin against the 
external os. This applied at night and removed through a 
speculum the following morning, the character and quantity 
of the discharge from the cervix can be noted. The differen- 
tiation between endocervicitis and endometritis is still more 
difficult. In many cases, indeed, we may not be able to say 
definitely that a cervical catarrh is not associated with more 
or less inflammation of the endometrium. The enlargement 
and thickening of the cervix demonstrate that it is the seat of 
inflammation. It is sometimes difficult to differentiate be- 
tween inflammation and malignant disease of the cervix. In 
the former the hypertrophy is more general and uniform, the 
tissues are more or less firm, but not hard, and show no in- 
clination to friability. In malignant disease the cervix may 
at points be hard and indurated from the presence of an in- 
filtrate which is more or less localized. An excavated ulcer 
may be present, covered with friable, easily broken-down tissue, 
which will crumble and become detached under the finger, while 
the base is hard and resisting. Hemorrhage and a profuse, foul- 
smelling discharge are prominent symptoms. When the condition 
is such as to leave one in doubt, a test excision should be made 
a.nd the excised tissue subjected to microscopic investigation. 

433. Prognosis. — The curability of endocervicitis is de- 
pendent upon the general health of the patient, the duration 
of the disease, and the extent of involvement. Not infre- 
o^uently it will be found that these patients have passed through 
the hands of a number of physicians, and, therefore, extreme 
care must be exercised as to the prognosis. The result is less 
favorable when there is a large amount of secretion and ap- 
parently but little glandular degeneration. 

434. Treatment. — First, constitutional: The patient should 
be encouraged to take outdoor exercise, and not infrequently 
change of air will prove of decided value. Tonics, such as 
quinin, iron, strychnin, arsenic, and the bitter tonics, will be 
of advantage. Indigestion should be corrected, regular action 
of the boAvels secured, and sexual rest advised. 

Second, local treatment: In the nullipara it is advisable 
to give hot vaginal douches through a fountain syringe under 
moderate pressure for ten to fifteen minutes each night, having 



3S2 



GYNECOLOGY 




Fig, 297. — Lines of Incision for Contracted or 
Pinhole Os. 



the patient preferably in the recumbent position. Doubt- 
less in some cases the hot water thrown with force from a bulb 
syringe against the cervix will have a more marked modifying 

influence upon the hy- 
perplastic process and, 
therefore, it should sup- 
plant the fountain syr- 
inge. The temperature 
of the water should be 
from 110° to 115° F., 
and the patient should 
be advised to remain 
in bed following the 
douche. Astringents 
can be added, such as 
a solution of zinc sul- 
phate (5j-ij-water Oij), 
powdered alum (5j~ 
Oij), lead acetate (5j- 
ij-Oij), or the latter 
and zinc sulphate may 
be combined. ]\Iild so- 
lutions of antiseptics may be substituted for the astringent, as 
hydrargyri bichlorid (1:4000), formalin (1:2000), but these 
agents present no special advantage over the douche of sodium 
chlorid, Bj, water Oij. 
The OS, when narrow 
and contracted so that 
drainage is ineffective, 
should be notched bilat- 
erally with scissors, to 
permit the escape of the 
mucus. The lips should 
be trimmed, making a 
funnel-shaped opening. 
(Figs. 297 and 298.) 
When the secretion con- 
tinues, local applications, 
such as tincture of iodin 
or carbolic acid, a satu- 
rated solution of iodin 
crystals in carbolic acid, p-, 
95 per cent., can be em- 
ployed; the former in 

mild, the latter in more severe, cases. Heywood Smith advises acid 
nitrate of mercury ; De Sinety, chromium trioxid. Better results 




—Union of Vaginal and 
Mucous Membranes. 



Cervical 



INFLAMMATIONS. 383 

are secured from the employment of the milder agents, as zinc sul- 
phate or chlorid gr. x, aqua f § j, silver nitrate gr. x-xv-5 j, or so- 
lution of argyrol (20-40 per cent.). In making an application, 
the mucus should first be removed from the canal with a cotton- 
wrapped applicator or a blunt curet. When the mucus is very 
tenacious, its removal is greatly facilitated by throwing in a few 
drops of hydrogen dioxid by means of a pipet, after which 
it is more readily removed with the blunt curet. This step is im- 
portant to prevent the application being coagulated by the 
mucus without reaching the affected surface. After the ap- 
plication any surplus fluid should be removed, and a tampon 
of cotton or of gauze saturated with glycerin should be placed 
beneath the cervix. A 25 per cent, solution of ichthyol in 
glycerin, or ichthyol in lanolin, of the same strength, may 
be applied to the cervical canal with a cotton-wrapped probe, 
or a small pledget of gauze or cotton anointed with it may 
be carried into the dilated cervix, or a tampon medicated with 
it may be applied to the eroded cervix. Ichthyol is advisable 
because of its germicidal action. The application of such a 
tampon will not infrequently result in the desquamation of 
an epithelial cast, followed by a regeneration of the epithelium 
and restoration of a healthy appearance of the cervix. The 
application of a saturated solution of iodoform in ether is ad- 
vised. Ether stimulates contraction of the glands and forces 
out the secretion, while the iodoform remaining acts as an 
antiseptic. In the multipara endocervicitis is not infrequently 
complicated by retroflexion, subinvolution, or laceration of 
the cervix. The first consideration should be to relieve conges- 
tion by scarification of the surface, puncture of retention cysts, 
employment of hot astringents or antiseptic douches, and the use 
of medicated tampons. Some form of glycerin medication upon 
the tampon is especially efficacious in causing profuse depletion. 
The displacement should be corrected and the organ should be 
maintained in a proper position by a tampon or by the use of 
the pessary. When the cervical mucous membrane is much 
everted and the lips are widely separated by laceration of the 
cer\dx, the relief of the engorgement and congestion can be over- 
come by the employment of Emmet's operation. The uterine 
congestion may be greatly decreased by local depletion through 
scarifying or puncturing the cervix. Such depletion is of special 
valtie where a number of glands of Naboth have become obstructed 
and have formed retention cysts. Evacuation of the cysts 
and the introduction of tincture of iodin or carbolic acid into 
their cavities produce a sufficient amount of inflammation to 
obliterate them and relieve the pressure. In very obstinately 
chronic cases destruction or removal of the diseased 8:landular 



384 GYNECOLOGY. 

tissue is imperative. It may be accomplished by the use of 
the PaqueHn thermocautery or by various caustics. Skoldberg 
recommends zinc -alum sticks, which are made by running 
together into molds equal parts of zinc sulphate and alum, 
forming a small stick, which is carried into the cervix and 
retained by a plug of gauze in the vagina, which also re- 
ceives the discharge. Silver nitrate in solid stick was formerly 
much used for this purpose. The latter method of treatment 
is required only in exceedingly severe cases, and its application 
should be extremely limited. It cures by destruction of the 
mucous membrane and glandular structure, substituting for 
them cicatricial tissue. It should not be used where there 
is danger of the cervical canal becoming so contracted as to 
interfere with drainage from the uterine cavity. Colpe, finding 
that an inflammation of the cervix did not yield to the use of 
astringents and caustics, examined the secretion and found 
present mycotic spores, after which he used lactic and salicylic 
acids, with immediate relief. 

Electricity has its advocates — the negative pole is introduced 
into the cervix, while the positive pole is placed upon the abdo- 
men. It is questionable, however, whether this plan of treat- 
ment has any advantage over other caustic measures. The use 
of the sharp curet not only removes the glands from the cervical 
canal, but, as advocated by Thomas, scrapes away the arbor vitse 
from the internal to the external os. This measure not infre- 
quently has to be repeated a second or even a third time before 
relief is complete. When there is very marked eversion or an 
eroded, deeply fissured surface, Schroder's operation should be 
performed. This consists in the formation of a single flap in 
each lip. The method of procedure has been described. (Sec- 
tion 336.) Martin removes a larger amount of the cervix, and 
combines amputation with excision. He splits the cervix into 
two lips, cuts through the cervical mucous membrane on the 
posterior lip above the diseased portion, then removes as much 
of the lip as is necessary, and stitches it. The anterior lip is 
treated in the same way. 

435. Acute Metritis and Endometritis. — In acute inflamma- 
tion the pathologic changes are not confined to the endometrium, 
but rapidly involve the entire organ. In the nonpuerperal 
uterus they are excited by infection from gonorrhea, or follow 
trauma, induced by exploratory operative procedures, or result 
from exacerbations of the chronic state. The nonpuerperal 
cases are rare and scarcely ever fatal or sufliciently threatening 
to require hysterectomy. Such an inflammation is generally 
brought on by an infection which has occurred during parturition 
or abortion, and, consequently, is more an obstetric than a 
gynecologic condition. 



INFLAMMATIONS. 385 

Infection is favored: 

1. By protracted labor during which the tissues have been 
subjected to bruising or laceration. 

2. Through want of skill or of cleanliness in the practice of 
manual or instrumental procedures. 

3. From the retention of clots or of portions of placenta or 
decidua after labor or abortion. 

4. By the presence of septic germs in the genital canal prior 
to the occurrence of gestation, by their introduction during the 
process of delivery or in the subsequent convalescence. 

436. Pathologic Alterations. — The infection is originally im- 
planted in the degenerated mucous membrane, the blood-clots 
of the uterine sinuses, the site of the placenta, or in retained 
portions of the placenta or decidua. Intense hyperemia results, 
with alterations in all the tissue elements. The gland lumina 
are dilated by the increased secretion and proliferation of the 
glandular epithelium. Inflammatory infiltration takes place 
into the tissues, with subsequent degeneration and destruction 
of the cellular elements. The mucous membrane becomes 
greatly swollen and edematous. The epithelium is found 
granular and desquamating. The blood-vessels become engorged 
and thrombosed. Inflammatory material is poured into the 
cellular tissue, which may terminate in abscess formation, either 
in the wall or sinuses or both. 

These pus -pockets, at first small and localized, increase in 
size, the intervening walls break down, and an abscess of con- 
siderable size may form, which may rupture into the uterine 
cavity and thus terminate favorably, or a large portion of the 
uterus may become gangrenous, causing serious detriment to 
the health, and even loss of life. In an autopsy upon a patient 
who died under my care in the Philadelphia Hospital the entire 
fundus was found to have been completely destroyed. 

437. Varieties and their Source. — The symptoms will be 
found to depend upon the character of the infection, and this 
can be divided into sapremic and septicemic. Sapremic infec- 
tion is induced by the action of the saprophytes upon retained 
blood-clots and portions of the decidua or placenta, which 
cause decomposition of the retained tissue, with the subsequent 
absorption of the decomposing products. Decomposed material, 
when undisturbed, presents a soil favorable for the implantation 
of septic infection. Septicemia, however, occurs much more 
frequently as a primary disorder induced by the entrance of 
pathogenic germs through fractures of the mucous membrane 
of the uterine body, cervix, vagina, or vulva. We have already 
asserted that inert pathogenic germs which inhabit the vagina 
can, by changed conditions, be stimulated into activity, but 

25 



386 GYNECOLOGY. 

they are, however, more frequently introduced from without, 
through failure of the physician or nurse to observe proper 
antiseptic or aseptic precautions. 

438. Symptoms. — Sapremia occurs ' in from three or four to 
ten days subsequent to delivery. The onset of the trouble is 
rather sudden, and is manifested by elevated temperature and 
repeated rigors. The patient may have severe chills, and daily 
temperature varying from 102° to 105° F. The lochial dis- 
charge may be absent, or, if present, is exceedingly foul. The 
patient generally manifests but little tenderness upon pressure. 
Manipulation over the uterus may be followed by contraction 
and the expulsion of a large offensive mass, after which the 
patient will improve, or she may have quite profuse bleeding. 
Digital examination discloses the presence of retained masses 
and affords evidence of their decomposition. The onset of 
septicemia is more insidious, but the symptoms occur earlier. 
The reaction induced by septicemia will depend upon the condi- 
tion of the patient, the time of the infection, and the virulence 
of the infective poison. As early as the second or third day, 
not infrequently upon the first, the patient will exhibit an 
elevation of temperature, which gradually increases. She 
suffers from pain or tenderness in the lower abdomen, which 
may be so marked as to confine her to the dorsal decubitus, 
with her limbs flexed and unable to exercise the slightest muscular 
action, because of pain. Not infrequently the bladder becomes 
greatly distended; the pulse is rapid, varying from no to 140; 
respirations frequent, and the temperature displays a 'range 
from 101° to 107" F. The lochial discharge is arrested or free, 
and may be mucous, mucopurulent, ichorous, or sanguinolent. 
It may have a stale, sickening smell or be almost free from odor. 
The cervix and vagina, upon inspection, may appear normal 
or highly inflamed, swollen, and covered with glairy mucus, 
or exhibit patches of diphtheric exudate. The uterus is likely 
to be smooth, swollen, and exceedingly tender to pressure. 
The cervix will appear lacerated and boggy. The entire organ 
will be found enlarged, edematous, and flabby. When the 
inflammation is confined to the uterus, the organ will be tender 
-and enlarged, but not so sensitive as to preclude palpation. 
If, however, the peritoneal coat is involved, the pain and tender- 
ness will be very acute; the limbs are drawn up to protect the 
abdomen from pressure of the clothing and to relieve the traction 
upon the abdominal wall. The progress of the disease will 
depend upon the virulence of the poison and the resistance 
of the patient. In the sapremic condition the source of origin 
of the disease may be expelled and the patiently rapidly pro- 
gress toward recovery. A patient suffering from septicemia 



INFLAMMATIONS. 387 

may be so fortunate as to secure immunity against its further 
progress and slowly recover. The disease may become localized 
and a pus-collection be spontaneously or artificially evacuated, 
or the general system may become so infected that, notwith- 
standing every therapeutic procedure, the patient succumbs. 
An unfavorable prognosis is indicated by a persistent high 
temperature, a pulse-rate continuously above 130, and the 
absence of localized foci. If the serious symptoms subside 
and the general condition of the patient improves, but a rapid 
pulse-rate continues, associated with an evening temperature 
of 100° F. or over, the patient should not be regarded as out 
of danger. This disorder was formerly known as puerperal 
fever and supposed to be due to some obscure poison charac- 
teristic of the condition. The investigations of Semmelweis 
and others demonstrated that it was analogous to surgical 
fever and due to a similar cause. The disorder is hydra -headed 
in its manifestations, and makes its invasion by one of three 
routes: through the continuous mucous membrane of the 
body of the uterus and Fallopian tubes to the peritoneum; 
through the blood-vessels or the lymphatics. Thus we may have 
inflammation of the structure of the uterus, the Fallopian 
tubes, the ovaries, the pelvic cellular tissue, or the pelvic perito- 
neum, or even all combined. Any of the veins of the body 
may become involved in the septic phlebitis, but the condition 
occurs most frequently in those of the lower extremities, caus- 
ing the condition formerly known as milk-leg, which we now 
recognize to be an infective phlebitis. It may manifest itself 
also by a severe lymphangitis. The disease may rapidly in- 
A^olve the general system, giving rise to profound symptoms 
of septicemia without any special localization. 

439. Diagnosis. — The early differentiation between sap- 
remia and septicemia is very important. The former, being 
associated with retained decomposing products, manifests 
itself several days after delivery. Symptoms develop suddenly 
in a patient who seemed to be undergoing a normal convales- 
cence. The lochial discharge, where present, is exceedingly 
offensive. A digital examination discloses a clot, a portion 
of placenta, or a portion of decomposing membrane within 
the uterine cavity. These products, when removed, have a 
very offensive odor, and with their disappearance the symptoms 
rapidly subside. In septicemia the symptoms occur more 
insidiously, and at an earlier date following delivery, unless, 
however, the infection should have been implanted late. The 
occurrence of elevation of temperature following a delivery 
should be regarded as a danger-signal, Avhich should cause 
the attendant to make a careful investigation of the history 



388 GYNECOLOGY. 

of the case, together with a judicious interrogation of the phy- 
sical signs. The condition of the breasts should be ascertained, 
for not infrequently women have a high temperature con- 
comitant with the establishment of lactation. The breasts 
become greatly distended, caked, and hard. The temperature 
of the patient reaches 105° F. or over. Not infrequently 
the nipples may be the source of infection, which may lead to 
the occurrence of a mammary abscess. Typhoid fever and 
malaria are frequently mistaken for sepsis and vice versd. The 
possibility of these conditions should be excluded by a careful 
examination of the blood; finding in malaria the Plasmodium 
and in typhoid fever the securing of a positive Widal reaction 
and the examination of the urine are considered sufficient 
evidence to establish the diagnosis. Furthermore, the typhoid 
bacillus may be found in the urine and also occasionally in 
the blood. A digital examination excludes sapremia when 
it reveals the walls of the uterine cavity smooth and free from 
any decomposing products. Intoxication from morbid prod- 
ucts in the intestinal tract may sometimes closely simulate 
septicemia. It was quite recently my privilege . to see, 
with two young doctors, a young woman who was suffering 
from a very high temperature with some abdominal distention, 
in whom there were no signs of any localization of sepsis. The 
patient had been delivered a week prior to the manifestation 
of symptoms. Examination disclosed the uterine cavity free 
from any decomposing material, and absence of tenderness 
over the uterus. The woman had had some fifteen foul-smelling 
stools during the preceding twenty-four hours. It was her first 
confinement, and there was a history of her having undergone a 
curetment some three years before. She had been very care- 
fully managed during her confinement, with every aseptic 
precaution, and had been cared for by a well-trained nurse. 
The inference of the attendants w^as that she had had some 
local accumulation in a tube prior to her delivery, from 
which this infection had developed. But as I found the uterus 
free from any tenderness or undue enlargement, no sign of in- 
fection in the vagina, and she had what seemed to me no tender- 
ness or swelling about either tube or ovary, I reasoned, there- 
fore, that if such local cause had existed, it should still show 
evidence of its presence, and in view of the very evident in- 
testinal disturbance, I ascribed the symptoms to an intestinal 
infection, and suggested measures for its correction. The 
rapid subsidence of the symptoms and recovery of the patient 
confirmed the diagnosis. 

Having reached a diagnosis in septicemia, by exclusion, 
it is then desirable to recognize and treat the local manifes- 



INFLAMMATIONS. 389 

tations promptly. These we determine by the size and evidence 
of laceration of the uterus, the existence of patches of diphtheric 
exudation in the vagina or uterus, and the possible form and prog- 
ress of the infection. Metritis will be indicated by a large, 
swollen, more or less tender and boggy uterus; perimetritis or 
pelvic peritonitis by extreme tenderness in the lower portion 
of the abdomen, pain and anxiety of the patient, with a fre- 
quent, rapid, wiry pulse, and high, sometimes low, and even 
subnormal, temperature; the latter symptoms, moreover, rather 
increasing the danger. Phlebitis will be recognized by tender- 
ness over the femoral and saphenous veins, as these are the 
ones in which the disease most frequently manifests itself. 
Lymphangitis is often indicated by the existence of inflammation 
of the cellular tissue and by pain and tenderness over the lumbar 
or inguinal regions. 

440. Prognosis. — Sapremia is a condition w^hich usually 
terminates favorably. The removal of the putrid products 
soon results in the subsidence of the constitutional intoxication. 
It should not be forgotten, however, that the putrid material 
affords a favorable soil for the development and propagation 
of septic germs, so that when a patient comes under obser- 
vation she may have been subjected to mixed infection. Under 
proper management this condition generally terminates in 
recovery. Septicemia is an exceedingly dangerous disease; 
its manifestations are so various that often when the patient 
survives she may be in a condition which cripples her for life 
and at the expense of serious sacrifice of important organs. 
The condition demands the most careful scrutiny of the prog- 
ress of the disease, with the resort to radical procedure when 
it is manifest that local foci are continuing its propagation. 

441. Treatment. — Prophylaxis is the most important treat- 
ment, but is so closely associated with the work of the obstet- 
rician that we will not consider it. A woman who develops 
symptoms leading one to suspect the occurrence of a septic 
process should at once be subjected to careful investigation. 
This careful scrutiny is advised in order to eliminate the possi- 
bility of other conditions being confounded with sepsis. Finally, 
a pelvic exploration should be made, and all decomposing 
products, such as blood-clots, portions of placenta, or remnants 
of decidua should be removed. The patient should be placed 
across the bed; if the abdomen is tender, an anesthetic should 
be given, and two fingers introduced into the uterus, which, 
with the hand over the abdomen, will permit the entire uterine 
cavity and wall to be thoroughly explored and all products 
and debris removed. The procedure not only removes the 
debris and contents of the uterus, but favors the pressing out 



390 GYNECOLOGY. 

of infected clots from the blood-vessels and uterine sinuses. 
This manipulation should be followed by intra-uterine douches 
of sterile normal salt solution, or, better still, a i per cent, 
saline solution, made up of 2 J grains sodium bicarbonate to 
7 J grains of sodium chlorid to the 1000, or formalin solution 
I : 1 500-1000, or sublimate solution i : 3000. When the uterine 
cavity is clear of decomposing masses and other causes are 
excluded, we are justified in accepting the diagnosis of 
septic infection, as distinguished from putrid intoxication. 
In septicemia, intra-uterine manipulation often will be unpro- 
ductive of any favorable result. The micro-organisms have 
already penetrated beyond the reach of any local measures. 
Curetment, by affording fresh avenues for infection, is harm- 
ful. The uterine cavity should be irrigated through a double- 
current tube three, four, or more times daily with a hot i per 
cent, saline solution or solutions of formalin or bichlorid. The 
latter solution (i : 3000) should be followed with normal salt 
solution to avoid the danger of mercuric poisoning. 

The removal of decomposing products, irrigation of the 
uterus, and the internal administration of salines in sapremia, 
or putrid intoxication, usually establishes early convalescence. 
Not infrequently, however, there will be a marked rise of tem- 
perature after such a procedure, but it soon subsides. Sepsis, 
on the other hand, is caused by micro-organisms which have 
entered the blood, and kill, not so much by their presence, as 
by the toxins or poisons which they generate. Researches 
have seemed to demonstrate that these toxins, obtained from 
pure cultures of the organisms and injected into the circulation 
of some of the lower animals, soon generate an antitoxin which 
acts as an antidote to the original poison. My early experience 
in the treatment of sepsis by the administration of the anti- 
streptococcic serum was such as to lead me to place greater 
reliance upon its efficacy in affording prompt immunity than 
the later experience of myself and colleagues would seem to 
justify. In severe cases as much as ten cubic centimeters 
(two and a half drams) in twenty-four hours should be employed. 
In less severe cases smaller doses, three to six cubic centimeters, 
can be employed. The dose should be administered daily 
until the abnormal symptoms subside. The advocates of the 
employment of serum-therapy in the treatment of puerperal 
sepsis are doubtless correct in their demand that the serum 
must be fresh. The want of success may have been due to 
this cause, as many have employed the imported serum of 
Marmorek. A requisite to accuracy is the careful bacterial 
investigation of the secretions, for it would not be reasonable 
to expect a satisfactory result by the employment of anti- 



INFLAMMATIONS. 391 

streptococcic serum in a staphylococcic infection. To be most 
effective, it is most important that the serum should be ad- 
ministered early and in good dose. The strength of the patient, 
and her consequent ability to fight the disease, should be main- 
tained by the administration of supporting remedies, by a 
nutritious, easily digested diet, and by the judicious use of 
stimulants. 

Ouinin may be given in suppository (gr. v-x) three or 
four times daily; strychnin, atropin, tincture of digitalis, digitalin 
or adrenalin chlorid solution (i : looo) should be administered 
hypodermically, as the indications demand. Action of the 
bowels should be secured by the proper use of salines, which 
facilitates the elimination of the infective products, though 
care should be exercised to avoid undue depletion. 

Intravenous Injections. — The intravenous injection of normal 
salt solution has been of great service to the surgeon in over- 
coming shock and in carrying patients over a critical condition. 
It has been demonstrated, also, that this procedure is service- 
able in low septic conditions by increasing the volume of the 
blood, thus diluting toxic material, promoting secretion, and 
the consequent elimination of poisonous products. The com- 
bination of chlorid of sodium with bicarbonate of sodium, 
making a i per cent, saline solution which should be in the 
proportion of 7 J parts of the chlorid of sodium to 2 J parts of 
bicarbonate of sodium, has proved especially efficacious in 
septic conditions, as it increased the phagocytes and the con- 
sequent ability of the patient to resist the progress of the in- 
fection. 

The brilliant results achieved by Professor Baccelli, in 
1889, in the treatment of pernicious malaria, by the intra- 
venous injection of hydrochlorid of quinin, has directed the 
attention of the profession to the intravenous injection of 
germicides. Baccelli later instituted the intravenous injection 
of corrosive sublimate in the treatment of syphilis, after the 
administration of mercury by other methods had failed. His 
experiments on the lower animals demonstrated the fact that 
albuminate of mercury, which was first formed, was redissolved 
in an excess of albumin. 

As it is known that the micro-organisms enter the blood, 
the introduction of germicidal agents into this fluid to render 
it an unfavorable soil for their multiplication is a plan 
which naturally appeals to the scientific mind. The difficulty 
has been to secure some agent which shall prove destructive 
to the specific germ in the hemal circulation, without inducing 
degenerative changes in the circulatory fluid. Carbolic acid, 
sublimate, and formalin have all been recommended as suit- 



392 GYNECOLOGY. 

able agents for this purpose. In a ■ recent case in which 
the conditions were such as to make it evident that death 
was imminent unless the poison could be arrested, I injected 
^ of a grain of sublimate in 500 centimeters of normal salt 
solution. The patient the following day developed an in- 
farct which cut off the circulation in the end of the nose, and 
she died at the end of forty-eight hours. As air, however, 
had entered, due to the faulty apparatus employed, it is not 
justifiable to condemn the bichlorid as the cause. Formalin 
has been especially commended of late, particularly by Barrows, 
of New York, and Maguire, of London. The latter, in his 
experiments, has injected solutions as strong as i : 500 into 
himself. This was followed by hematuria, albuminuria, cramp- 
like pains, and faintness. I have applied gauze, wet with 
formalin solution (i : 1500-2000), to the peritoneum, with com- 
plete destruction of the endothelial covering of the involved 
surface, so that I should regard the injections of solutions of 
formalin, therefore, under i : 5000, as extremely dangerous, 
and as it has been claimed that it is germicidal in solutions 
of I : 200,000, a weaker solution still would seem preferable. 
As the simple injection of water into the blood-vessels causes 
degenerative changes in the blood-corpuscles, it would seem 
much wiser that these injections should be made in combina- 
tion with normal salt solution. In cases, then, in which it is 
evident that the patient will succumb to the disease unless 
it can be arrested, we should feel justified in proceeding to 
extreme measures with the hope of affording relief; and with 
our present knowledge of conditions, I should favor the formalin 
in combination with a normal salt solution as being the least 
deleterious of the agents we can employ. I would advise against 
it being given in greater strength than i : 10,000. The beneficial 
results from the intravenous employment of this drug have 
not been sufficiently brilliant to compensate for its well-recog- 
nized disadvantages. 

Localization of infection may result in abscess formation 
in the uterine wall, in the pelvic cellular tissue, in the tube, 
in the ovaries, or in multiple abscesses in various portions 
of the body. The manifestation of such a local collection 
should be deemed an indication for prompt surgical inter- 
ference. The treatment necessarily must depend upon the 
site and extent of the lesion. If an exudate or inflammatory 
collection can be reached by a vaginal incision, through which 
the contents of the cavity can be evacuated, its sac enucleated 
and removed, or the cellular tissue opened up and drained, 
more serious destruction of tissue can often be avoided. Where 
the uterus remains large and extremely tender, or presents 



INFLAMMATIONS. 393 

indications of localized peritonitis or localized abscess formation, 
and the condition of the patient will permit, the abdomen can 
be opened and hysterectomy performed. It should be capable 
of demonstration that the uterus is the seat of irreparable dam- 
age or a focus for the continued distribution of infection before 
it is removed, because I have been consulted as to its removal 
in women who have recovered without operation, and even 
subsequently given birth to children. In doubtful cases the 
uterus can be explored by an incision through the posterior 
vaginal fornix, and in many cases the opportunity thus granted 
for peritoneal drainage will afford the required relief. The ex- 




' c- 



/I 



t- 



a. — — ^ * -'. • .J 



' ' ''■■' L'l ' 



'-^M 



'%^,. 



^ 



■^ 



Fig. 299. — Interstitial Endometritis. 
a. Free uterine surface. 6, 6, h. Hyperplasia of connective tissue. c,c,c,c. 
Obliteration of glands, d. Choking of gland from increase of fibrous tis- 
sue, e, e. Glands occluded and somewhat dilated. 

cision of a section of an infected vein has been successfully per- 
formed, but one must be satisfied that the condition is not dif- 
fuse before resorting to such a procedure. 

When the temperature is elevated, the skin hot and dry, 
associated with tympanites and repeated vomiting, the most 
effective plan of treatment is to irrigate the stomach with hot 
normal salt solution, followed by intercolonic irrigation. The 
latter should be continued over several hours, or a quart of 
normal salt solution should be injected into the bowel every 
hour. The better plan is to elevate the foot of the bed and 
through a double rectal tube subject the rectum to more or less 



394. GYNECOLOGY. 

continuous irrigation with a one per cent, salt solution. The 
administration of large quantities of salt solution promotes elim- 
ination. The tongue and skin become moist, the secretion of 
urine increased, the pulse increases in volume, and the tempera- 
ture becomes reduced. 

442. Chronic endometritis is an inflammation of the mucous 
membrane of the body of the uterus. It rarely, if ever, is 
the consequence of acute endometritis, but more frequently 
follows subacute processes and long-continued hyperemia. 
It is divided by Ruge into glandular, interstitial, and mixed, 
according to the structure of the mucous membrane most 
extensively involved. In all varieties of inflammation the 



^M 




h-^' 



^7 



Fig. 300. — Hypertrophic Glandular Endometritis, showing Increase in Size 

and Numbers of Glands, 
a, a. Glands dilated and containing secretion, h. Infiltration of leukocytes. 

entire structure of the membrane is necessarily more or less 
affected. With thickening of the mucous membrane the glands 
become elongated, dilated, bent, and tortuous. Cells become 
swollen and proliferated, resembling those of the decidua. 
The vessels of the deeper portion of the mucosa are dilated 
and in a state of congestion. The mucous membrane is not 
infrequently several times its normal thickness, soft, spongy, 
and easily scraped away. The surface presents vegetations 
or growths, which, according to De Sinety, are of three forms. 
In one, the tissue consists of dilated blood-vessels; in the second, 
of dilated, hypertrophied glands (Fig. 301); in the third, of 



INFLAMMATIONS. 



395 



embryonic tissue containing but few blood-vessels and only 
traces of glands. With these conditions are associated three 
kinds of discharge — sanguinolent, leukorrheal, and mucopuru- 
lent. As a result of the changes in the mucous membrane, 



^f^>f^-?\ 









0s%"'''"<' <-0<f:.i>.} -'f'hr]3 



^X 4/^ 



Fig. 301. — Hypertrophic Glandular Endometritis. Vertical Section through 

the Mucous Membrane. 
a. Blood-vessel distended with blood-cells, h. Gland penetrating muscular wall. 

not infrequently portions project as polypoid masses, which 
consist of either glandular or vascular structure. (Fig. 302.) 
In this condition the mucous membrane is thickened and granu- 
lar in appearance, and the state has been called villous de- 



396 



GYNECOLOGY. 



generation, or endometritis fungosa. With cell-proliferation 
in its connective tissue and the subsequent contraction of the 
gland its structure is compressed and obliterated, so that 
the surface is almost free from glands. Or, again, the orifices 
of the glands' ducts in places become occluded and cysts result. 
The hyperplasia of the uterine mucosa in some cases results 
in the desquamation of the epithehal layers at each menstrual 
period. This desquamation may take place in the formation 
of shreds or in a complete cast of the uterus, in which the orifices 
of the Fallopian tubes and the internal os are recognized. This 
condition is known as exfoHative endometritis, membranous dys- 
menorrhea, or, probably better, menstrual decidua. (Fig. 303.) 








Fig. 302. — Polypoid Masses Associated with Chronic Endometritis. 
a. Glands greatly dilated, with destruction of the intervening septum. 

443. Symptoms. — The disease arises after abortion or labor, 
as a result of an attack of uterine inflammation, or an attack 
of gonorrhea. Occasionally, it may begin insidiously and 
without any sign of a cause. It occurs more frequently in 
the muciparous, and is more common in the later menstrual 
life. Nulliparae are not exempt; CA'^en virgins are sometimes 
affected — a condition known as virginal endometritis. This 
especially occurs in narrowing or stenosis of the external os. 
A form of the disease occurs subsequent to the climacteric, 
when it is known as senile endometritis. Endometritis is 
characterized by the following symptoms: leukorrhea and 
menorrhagia. The discharge from the body of the uterus 



INFLAMMATIONS. 



397 



is less viscid than that from the cervix. It may be clear, but 
more generally is mucopurulent; occasionally it is tinged with 
blood, so that the patient imagines herself continuously un- 
well. The discharge flows freely or there is an apparent ac- 
cumulation. Retention of the discharge and its evacuation 
in considerable quantity occur when endometritis is complicated 
by retrodisplacements or when the os is small. The discharge 
may have an offensive odor and be so irritating as to give rise 
to extensive excoriation of the vulva. Excessive menstrual 
flow, or menorrhagia, may or may not be present. Occasionally, 
it will be so profuse as to occasion a suspicion of malignant 
disease and cause a profound anemia. The resulting loss of 




Fig. 303. — Membranous Dysmenorrhea. 



vasomotor tonus results in increased tendency to hemorrhage. 
Dysmenorrhea, or painful menstruation, is not so common 
as in disease of the appendages or in chronic metritis. It is 
especially marked when accompanied by the discharge of a 
menstrual decidua. The influence of endometritis upon con- 
ception is not fully determined, but the increased frequency 
with which women become pregnant subsequent to a curet- 
ment renders it evident that it has a restraining influence upon 
the occurrence of conception. Endometritis is a prolific cause 
of abortion. 

444. Diagnosis. — The existence of leukorrhea or of irregular 



398. GYNECOLOGY. 

and profuse menstruation, associated with enlargement of the 
uterus for which no explanation external to the uterus can be 
found, justifies the suspicion of endometritis. The history of 
abortion, or prolonged convalescence subsequent to labor, con- 
firms the suspicion. The use of the curet is of incalculable 
advantage in determining the diagnosis. Portions removed 
with the curet will show small-cell infiltration of the entire 
glandular tissue, without glandular hyperplasia, or marked 
hyperplasia of glands with proliferation of the glandular epithe- 
lium. The epithelial cells become enlarged and granular, lose 
their cylindrical shape, and resemble the decidual cell. Endo- 
metritis, when uninterrupted, extends to the deeper structures, 
producing metritis. It predisposes to malignant change. When 
permitted to pursue an undisturbed course, it may involve the 
peri-uterine covering. Deposits occur in the cellular tissue 
about the ovary or around the orifice of the Fallopian tube, or 
the disease involves the pelvic peritoneum. Neglected cases 
result in cellulitis, salpingitis, ovaritis, peritonitis, the for- 
mation of abscesses, the destruction of tissue in the organs, 
and not infrequently, alas! in loss of life. Senile endometritis 
is associated with retention of secretion which decomposes, 
producing an exceedingly offensive odor, and arouses the sus- 
picion of malignant disease (Dunning). The examination of 
such a uterus reveals its walls thinned; the mucous membrane 
consisting of a thin layer of connective tissue covered with a 
single layer of flattened epithelial cells. 

445. Treatment. — Constitutional treatment is of marked 
value, and will be discussed with chronic metritis. Prophylaxis 
will require rigid asepsis during labor or abortion, as well as 
in making gynecologic examinations. A rise of temperature or 
the suspicion of the retention of a portion of placental debris 
should be considered as indicating the necessity for thorough 
use of the curet, free irrigation, and, in many cases, gauze pack- 
ing. Laceration of the cervix or of the pelvic floor should 
have early repair. All suspicious discharges must be removed 
by treating the cause. Before the third or fourth day an en- 
dometritis of gonorrheal origin is best treated by frequent 
irrigation with antiseptic solution, such as permanganate of 
potash (i : 3000-2000), mercurol (i to 2 per cent.), protargol (0.5 
to I per cent.). If the acute symptoms have subsided, paint the 
cervix, and where the os is patulous, the cervical canal, with 
50 per cent, solution of ichthyol in water, or glycerin, and later, 
if the condition persists, curet and pack with iodoform gauze. 
Careful antiseptic or aseptic cureting is the proper form of treat- 
ment in all forms of endometritis, w^hether complicated or un- 
complicated. In serious cervical lesions, with much eversion 



INFLAMMATIONS. 399 

and thickening of the mucous membrane, cureting should be 
associated with Schroder's operation upon the cervix. Drainage 
is of incalculable advantage in endometritis when complicated 
with slight catarrhal salpingitis. It will also prove serviceable 
in mild forms of peri-uterine inflammation. Cureting should be 
considered contraindicated in well-established pathologic changes 
in the adnexa and in chronic peri-uterine inflammation unless 
immediately followed during the anesthesia by an abdominal 
incision for the correction of the pelvic lesions. In addition 
to curetment, intra-uterine treatment consists in the employ- 
ment of antiseptics and caustics. Free drainage should be con- 
sidered as a prerequisite to all intra-uterine treatment. The 
inflamed uterine canal is similar to a sinus. Unless the pent-up 
discharges have free vent, the irritation is aggravated. When 
the canal is patulous, large injections of a feeble antiseptic 
solution such as formalin (i : 2000), normal salt solution, or a 
two per cent, solution of bicarbonate of soda through a re- 
turn-current catheter can be employed. The latter solutions, 
when used, are as salutary as the more distinctly defined 
germicidal agents. If the cervical canal is insufliciently large, 
it should be dilated with laminaria tents, after which irri- 
gation should be practised. In mild cases the canal may be 
swabbed, by means of a cotton-wrapped applicator, with tinc- 
ture of iodin; in more severe cases, with carbohc acid. When 
the mucous membrane is thickened and tends to bleed or to 
furnish a profuse discharge, more active agents may be em- 
ployed: silver nitrate, gr. xxx, to aq. destil., 5ss-j; zinc chlorid, 
3j-iv to f 5j ; chromium trioxid, gr. x-xxx, to f 5j ; fuming nitric 
acid, acid nitrate of mercury, tincture of chlorid of iron, pencils 
of silver nitrate, zinc chlorid, zinc sulphate, copper sulphate, 
or formalin. When strong caustics are used, precautions 
must be practised to protect the healthy vagina from con- 
tact with the solution. Indeed, in my judgment the employment 
of the strong caustics is very infrequently required. Much more 
is to be gained where a strong effect is desired by the use of the 
curet and the subsequent applications of the milder agents, as 
argyrol (10 to 50 per cent.), protargol (5 to 10 per cent.), or the 
ordinary tincture of iodin. A mass of absorbent cotton should 
be placed beneath the cervix prior to the appHcation, and 
the superfluous caustic should be removed by sponging before 
the pledget is withdrawn. Pencils are objectionable in that 
they produce sloughing of the cervical mucous membrane 
and cause the development of atresia. 

Tampons. — Intra-uterine treatment should be supplemented 
by placing beneath the cervix a tampon, preferably saturated 
with a preparation of glycerin, a 50 per cent, solution of boro- 



400 GYNECOLOGY. 

glycerid in glycerin, a lo to 15 per cent, solution of ichthyol 
in glycerin, or a 25 per cent, ointment of ichthyol in lanolin. 
The following prescription is an excellent astringent and anti- 
septic : 

B . Pulv. alum f ^ j ^ 

Acid, carbolic ^vj 

Glycerin., Oj. 

Various ointments, either astringent or alterative, with 
lanolin as a base, may be used upon the tampon. A tampon 
improves the circulation by raising and maintaining the uterus 
at a higher level. The antiseptic tampon may be retained from 
twenty-four to seventy-two hours, according to its character. 
When the tampon is not used, or after its removal, a vaginal 
douche of two or three quarts of hot salt water (110° to 120° F.) 
should be used twice daily, with the patient in the recumbent 
position. When using very hot injections cover the vulva 
and perineum with vaselin, to prevent burning. The employ- 
ment of rock-salt, an ounce to the quart, in a douche, 
promotes its efficiency. Scarification under continuous irri- 
gation will often prove of advantage, and is more effective 
than leeches. An iodoform gauze tampon should follow. Intra- 
uterine injections have been employed for endometritis, but 
should never be used unless the canal is sufficiently patulous 
to permit the escape of the superfluous fluid. The preferable 
plan is to employ a pipet or syringe by which one, two, or three 
drops may be introduced. Occasionally, even this small quan- 
tity will cause violent uterine colic. These attacks are not 
necessarily dangerous, but they are not calculated to encourage 
the continuation of treatment. 

The treatment par excellence in chronic endometritis is 
the use of the curet. In senile endometritis the important 
consideration is drainage; to insure this, it may sometimes 
be necessary to employ a tube. The cavity should be frequently 
irrigated with an antiseptic solution. 

446. Chronic Metritis. — Chronic metritis is an inflammation 
in the muscle-wall of the uterus, leading, when long continued, 
to increased connective-tissue formation. The term metritis 
is used in a comprehensive sense, and comprises conditions 
which have been described by different writers under such 
terms as chronic parenchymatous inflammation (Scanzoni) ; 
subinvolution (Simpson) ; diffuse proliferation of connective 
tissue (Klob) ; infarction (Kiwisch) ; hyperplasia of flbromuscular 
tissue, similar to fibroid tumors (Virchow) ; diffuse interstitial 
metritis (Noeggerath) ; irritable uterus (Gooch). The term 
may be criticized from a pathologic standpoint, as there is 



INFLAMMATIONS. 401 

no chronic inflammation of the muscle-fiber of the uterus, 
but an increased amount of connective tissue, out of proportion 
to that of the muscle-fiber. Clinically it is satisfactory, as 
it enables us to comprise under one term a variety of conditions 
which may be developed from different causes but produce 
a similar group of symptoms. It has been objected to this 
term that, by inference, there has been a profuse acute inflam- 
mation, which is not the case, as chronic inflammation of the 
uterus does not follow the acute. It is more correctly described 
as an increased tissue formation, dependent on long-continued 
congestion. The term chronic is applied to analogous forms 
of inflammation in other organs and structures of the body, 
as cirrhosis of the liver, which describes a condition similar 
to that which is found in the uterus. Subinvolution is, in 
some English books, described separately, though it is due to 
the same cause. 

The differential diagnosis between subinvolution and chronic 
metritis is impossible, and the treatment of the two conditions 
does not differ. The altered condition of the uterus will vary 
with the period at which the patient comes under observation. 
In the early stages the organ is enlarged, hyperemic, and soft. 
Later, it may decrease in size, though it is still large, and then 
becomes hard, indurated, and anemic. The enlargement of 
the organ is uniform, so the shape is not altered. Upon open- 
ing the abdomen of such a patient the peritoneal surface will 
present a normal color, or patches of extravasated blood may 
be present. On section, in the early stages the tissues will 
be soft, hyperemic, easily incised; later, firm, cartilaginous, 
presenting a whitish color, the walls thickened, and the cavity 
of the uterus enlarged. Not infrequently the organ will be 
found as firm and dense as a mature fibroid growth. During 
the first period, De Sinety says, the dominant lesion is the 
presence of a large number of embryonic elements through- 
out the thickness of the muscular wall. These are more par- 
ticularly situated around the blood-vessels, . or they may form 
islands more or less separated from one another. The second 
period is characterized by two changes: first, marked dilatation 
of the lymphatic spaces; second, localized hyperplasia around 
the blood-vessels. We raay find it difficult to determine whether 
the muscular tissue remains normal, or is present in decreased 
quantity. Fritsch examined uteri removed for cancer, and 
found associated evidences of chronic metritis, in which the 
following pathologic changes were noticed: The arrangement 
of the muscular fiber and connective tissue is less regular than 
in the normal, and the latter is greatly increased in quantity. 
Blood-vessels are more numerous and tortuous. The vessel 
26 



402. GYNECOLOGY. 

lumen is contracted, its tunica media is thickened, and the 
contour of the vessel is masked by the degeneration of the con- 
nective tissue in its wall. The lymphatic spaces, instead of 
being narrow clefts, are gaping; the peritoneum is thickened. 
Both Corneuil and Snow-Beck described an increased num- 
ber of round and oval globules with amorphous tissue in the 
uterine walls. The increase in the size of the organ is due to 
the presence of this rather than to the increase of muscle-fiber. 

447. Etiology. — The causes of chronic metritis are divided 
into two classes : the predisposing and the exciting. The former 
may be divided into: (a) Those which operate by interference 
with the normal involution of the puerperal uterus; (6) those 
which are due to the production of repeated or protracted 
congestion. The first class comprises: first, retentions within 
the uterus of portions of placenta, membranes, or blood-clots; 
second, cervical lacerations; third, pelvic inflammations subse- 
quent to labor; fourth, too short convalescence following de- 
livery; fifth, nonlactation ; sixth, repeated miscarriages. Two 
factors are essential to the accomplishment of involution: 
first, fatty degeneration of the muscle-fiber; second, removal 
of the products of degeneration. Now, subinvolution or failure 
of the uterus to undergo complete involution is due not to want 
of degeneration of muscle-fiber, but to substitution of con- 
nective tissue for the products of this degeneration. Metritis, 
then, is generally found in women who have borne children, 
and it has been asserted that involution is retarded by the 
removal of- the ovaries, although a patient of mine who 
completed her gestation after the removal of both ovaries 
did not manifest any failure in the process of involution. Any 
irritation in or about the uterus will cause a chronic metritis, 
and this explains the effect of retention of portions of the placenta 
or membranes, of lacerations of the cervix, and of the existence 
of peritonitis or cellulitis, as these conditions interfere with 
the circulation, which is also aftected by premature getting 
up following labor. The organ is heavy, and the increased 
weight leads to its being displaced to a lower level, producing 
passive congestion. Passive congestion is decreased by any 
cause which increases uterine contractions; the physiologic 
stimulus of nursing excites contraction reflexly through the 
mamm^ and favors involution. Abortions are especially in- 
strumental, for the reason that the patients do not take so much 
care of themselves as they w^ould subsequent to a labor, and 
the stimulus of lactation is absent. After an abortion con- 
ception is likely to occur before the process of involution is 
complete, and this favors the recurrence of abortion. 

The second class of cases, which operate through production 



INFLAMMATIONS. 403 

of repeated or protracted congestion, includes displacements 
of the uterus, the presence of tumors in or near it, and causes 
that produce increased flow of blood to the uterus, such as 
endometritis and the free use of caustics. To this class also 
belong malformation, incomplete development, congenital ante- 
flexion, conic cervix, stenosis of os, improper clothing, expo- 
sure to cold, and masturbation. Metritis is favored at each 
menstrual period, by exposure to cold, especially when the 
uterus is displaced or the cervix is contracted or lacerated, by 
excessive copulation or its practice during menstruation, and 
by gonorrheal infection from an incompletely cured husband. 

Chronic contusions from the use of a pessary may engender 
the inflammation. The intra-uterine stem-pessary is capable 
of doing the most injury. 

448. Symptoms. — In the large majority of cases the patient 
will date her trouble from a confinement. Not infrequently 
she will report repeated abortions, and that she subsequently 
regained her health very sloAvly. 

The symptoms are not characteristic, but are similar to 
those found in cancer, fibroma, displacements, and other local 
disorders. They are: weakness; pain or aching over the lower 
lumbar and sacral regions; a sensation of weight and bear- 
ing down, as if the pelvic organs were to be extruded; an ap- 
parent loss of power in the limbs; points of anesthesia over 
the anterior surface of one or both thighs; painful contractions 
of the uterus; irritable bladder; constipation; loss of all plea- 
surable sensation during the sexual relation; pricking pain 
in the eyes and weak sight; photophobia; occipital pain, but 
more frequently pain over the coronal suture ; and disturbances 
of menstruation, as dysmenorrhea, abnormal bleeding, menor- 
rhagia, or metrorrhagia. In weak patients are found amen- 
orrhea, leukorrhea, hydrorrhea, hydrorrhoea gravidarum, puer- 
peral hydrorrhea associated with retention of portions of placenta 
and clots. Not infrequently there are loss of appetite, nausea, 
dyspepsia, and enfeebled assimilation. The patient is pale, 
anemic, and exceedingly weak, with dark circles beneath her 
eyes. She suffers from palpitation and a sense of oppression, 
and is exceedingly despondent and profoundly melancholic. 
Acute mania, epilepsy, hysteria, and neurasthenia are occasion- 
ally induced, and are always aggravated by the existence of 
chronic metritis. The diseased condition under discussion is 
responsible for the majority of cases of semi-invalidism. The 
patient is continuously conscious that she has a uterus; the 
distress is increased by exercise and lessened by rest. The 
constipation and digestive disturbances are aggravated and 
increased by dread of pain and by her sedentary habits. The 



404 GYNECOLOGY. 

patient can suffer from acute exacerbations, with diarrhea and 
rectal tenesmus, as a result of extension of the inflammation to 
the rectum. 

Menstrual disturbances are common, largely induced by 
the accompanying endometritis, called, from the bleeding, 
hemorrhagic endometritis. 

The hemorrhage is probably quite as often due to the dimin- 
ished contractile power of the organ as to the substitution 
of connective tissue for the muscle-fiber. The associated 
disease of the mucous membrane adds to the dysmenorrhea, 
which may precede, be simultaneous with, or follow the period. 
It is generally continuous with the period, in the form of in- 
creased backache, pressure, and pelvic discomfort. 

Leukorrhea is produced by alterations of the uterine mucous 
membrane. In the aged not infrequently a hydrorrhea de- 
velops, with a periodic discharge so offensive as to lead to the 
suspicion of the development of malignant disease. 

Sterility is a natural consequence of the prolonged existence 
of chronic inflammation, not only from alterations in the struc- 
ture of the wall and mucosa, but probably much more from 
the superadded changes in the pelvic peritoneum, affecting 
the tube and ovaries. The escape of the ovum may be pre- 
vented by extensive adhesions fixing the ovary, or through 
thickening of the ovarian tunica albuginea, which prevents 
its exit from the maturing Graafian follicle. The Fallopian 
tube may furnish the obstacle, through closure of its abdom- 
inal or uterine end, or by stricture along its course. 

In the earlier stages of the inflammation the susceptibility 
to pregnancy may be engendered by the conditions, while 
the existing changes unfit the internal uterine surface for the 
complete nutrition of the developing embryo, and abortion 
or premature discharge of the contents follows. The sub- 
stitution of connective for the muscular tissue, through the 
consequent uterine inertia, when gestation is completed, renders 
delivery tedious and increases the danger of postpartum bleed- 
ing. 

Chronic metritis is responsible for a large proportion of 
the sofa and bath-chair population — the nervous, debilitated, 
dyspeptic women who wander from physician to physician 
or crowd the watering-places during the summer. The con- 
dition is frequently unrecognized and untreated, and the patient 
is condemned to suffer deeper and deeper wretchedness. 

449. Physical Signs and Diagnosis. — The uterus is large, 
without a change in shape. The walls are firm and rigid — in 
later stages almost as resistant as a fibroid tumor. 

The organ may have a normal position, may be situated 



1 



INFLAMMATIONS. 405 

at a lower level, or may be displaced. It may be freely movable 
or more or less fixed; readily outlined or fixed in a mass of 
pelvic exudate. The organ is sensitive to pressure. 

Differential Diagnosis. — Pregnancy in the early stages pre- 
sents a history of cessation of menstruation and of increased 
discharge. The uterus is enlarged, the cervix soft, while the 
body bulges like a jug and is not resistant. Cancer usually 
involves the cervix, though the body may be the site of origin. 
In the latter the bimanual examination will disclose points of 
increased resistance. Bleeding results from severe manipu- 
lation, and an offensive, thin, and serous discharge will prob- 
ably be present. Pain is a frequent symptom, and occurs 
most severely toward evening. The use of the curet or digital 
exploration after dilatation with tents may be required to 
confirm the diagnosis. The cureted tissue in cancer will be 
friable from infiltration, exhibiting under the microscope the 
characteristic cellular structure. 

Small fibroids are frequently difiicult to recognize, especially 
when interstitial or submucous. The irregular enlargement, 
well-defined points of resistance, and frequently intermittent 
pain are diagnostic. Digital exploration of the uterine cavity 
determines the presence, size, and situation of the growth. 
Salpingitis is often associated with metritis, when it may be 
difiicult to determine which predominates. A small ovarian 
tumor may be the cause of hemorrhage. 

Rectal disease may produce symptoms simulating chronic 
metritis. The general health may be so affected as to cause 
the local manifestations to be overlooked. Thus, the patient 
may complain of persistent cough, difficult breathing, or pro- 
gressive emaciation, or the stomach may be the source of trouble, 
causing loss of appetite, fiatulence, and gurgling, and present- 
ing evidences of dilatation. She may have precordial anxiety, 
palpitation, or cardiac and vascular murmurs. 

It is a good rule to make a careful uterine examination 
in all cases of chronic disease. 

450. Course and Prognosis. — Metritis in all forms is obsti- 
nate and rebellious. The mucous membrane, muscular wall, 
and serous covering in turn are affected, followed by uterine 
sclerosis, cyst formation, and, finally, chronic metritis. In 
alterations of structure we can not hope to cure in the sense of 
restoration of altered tissues; we can hope only for arrest of 
the process, relief of congestion, and amelioration of unpleasant 
symptoms. 

451. Treatment. — The best treatment is preventive. It 
consists in thoroughly emptying the cavity of the uterus after 
labor; in early repair of lacerations; in the relief of inflam- 



40Cr GYNECOLOGY. 

matory conditions existing about the uterus; in stimulating 
involution of the organ by hot vaginal douches; in the ad- 
ministration of ergot and of remedies that will facilitate the 
contraction of its muscle-fibers ; in the exercise of such measures 
as will diminish congestion; in preventing the patient from 
rising too early from bed after pregnancy or abortion, and, 
when the condition subsequently exists, obliging her to remain 
in bed several hours daily, and to avoid sedentary occupations 
and long standing. While it is important that the patient 
should have sufficient rest, it is equally desirable that this 
should not be excessive. A certain amount of exercise in the 
open air is as desirable as rest. Tight clothing should be ex- 
cluded. If the abdominal muscles, however, are very much 
relaxed, a snugly fitting abdominal binder affords great com- 
fort and relief. This relaxation of the abdominal muscles is 
not infrequently associated with relaxation of the vaginal 
walls, when the use of a ring-pessary gives comfort. The 
circulation of the pelvis should be stimulated by vaginal douches 
of either hot or cold water. The latter are more stimulating, 
but few patients can employ them. Patients should take 
a hot douche containing rock-salt, at a temperature of from 
103° F. to 120° F., for ten or fifteen minutes before retiring. 
These douches are more eft'ective when the patient is in the 
recumbent position. She can lie across the bed with her pelvis 
upon a basin or rubber pad, which should drain into a pail 
below, while her feet rest upon chairs. A douche bag, con- 
taining at least three pints, should be placed three feet above 
the level of the patient. Prior to its use the vulva and peri- 
neum should be coated with vaselin, to protect from the heat. 
The tube should be introduced to the cervix, and from three 
to ten pints of fluid should be used with each douche. Occa- 
sionally, warm baths should be used simultaneously with the 
vaginal douche. A cold hip-bath in the morning will be of 
great service. Medicated baths and waters are often of value. 
A course in hydrotherapy will frequently be serviceable. In 
catarrh or in scrofulous and chlorotic patients iron waters are 
beneficial. In nervous patients the character of the water 
is unimportant, but the patient should be encouraged to take 
large quantities. With dyspeptics, alkaline waters are desir- 
able. In the lymphatic and scrofulous cases waters impreg- 
nated with chlorid of sodium are very efficient. These are 
also of value in some forms of chronic metritis where engorge- 
ment of the uterine body predominates. Patients not infre- 
quently derive great advantage from change of air or scene, 
new surroundings, new relations, or a visit to the seashore 
or country. Constipation should be combated, preferably 



INFLAMAIATIONS. 407 

with foods, such as vegetables, Graham bread, and prunes; 
often effectively with other agents, as a teaspoonful of w^hite 
mustard in water at meals ; enemas to which glycerin is added ; 
the administration of mineral waters — ^the Friedrichshall water, 
Carlsbad salts, or Hunyadi Janos. The Carlsbad salts are of 
particular value in bilious patients. A teaspoonful should be 
dissolved in a glass of water and drunk in repeated sips during 
the morning. Friedrichshall and Hunyadi act best Avhen 
mixed with equal quantities of hot water. A good mixture is 
a tablespoonful of the f olloAving preparation : 

R . Magnesii sulph. , • • • 3 "^j 

Quinin. sulph gr. xxiv 

Acid, sulphuric, dilut., 

Tinct. capsici, aa f ;5 j 

Aqua, ad f J vj. M. 

SiG. — Tablespoonful three times daily. 

Contraction of the uterine muscles may be increased by 
the administration of ergot, Avhich should be given in doses 
of gtt. XX to f 5j of the fiuidextract t. d. When the condition 
is complicated with menorrhagia, extract of hydrastis canadensis 
may be combined. An effective prescription would be a mixture 
of ergot and hamamelis. (Section 224.) Potash salts are 
especially beneficial in chronic inflammation of the uterus. 
Chlorate of potash is highly recommended by Tait. lodid 
of potash, however, is equally eft'ective, and, when the patient 
is nervous and restless, may be combined with a bromid, giving 
of the iodid, gr. v, wdth bromid, gr. x, largely diluted with water, 
three times daily. Potash salts may be administered in the 
bitter tonics, as in compound tincture of cinchona or compound 
tincture of gentian. In the anemic and debilitated, iron, 
strychnin, quinin, arsenic, cod-liver oil, and malt extracts 
will prove beneficial. The general health should be carefully 
w^atched and any deranged condition of the various organs, 
should be corrected. During the menstrual period patients 
should be confined to the sofa. When the pelvic distress is 
marked, or when the metritis is complicated by inflammation 
in the surrounding structures, benefit will be derived from 
the use of counterirritants, in the form of small blisters over 
the inguinal region, or the use of iodin or of croton oil. A 
good mixture is croton oil, one part ; tincture of iodin, two parts ; 
sulphuric ether, five parts, which can be painted over the hypo- 
gastric and iliac regions until a crop of pustules arises. The 
application should then be discontinued until they have healed. 
Exercise care not to allow the application to be made in the 
groin. Blistering fiuid may be applied to the cervix and to 
the vault of the vagina, or tincture of iodin, or' a combinatio.i 



408- GYNECOLOGY. 

of tincture of iodin and glycerin, may be thus used. Scanzoni 
advocated this appHcation: 

R . Potass, iodid., gr. iv 

Glycerin., it^xxx. 

When cervical catarrh complicates the condition, punctur- 
ing or scarifying the cervix, under an antiseptic stream, will 
be beneficial. Considerable depletion can thus be effected 
and the patients relieved. After the bleeding has stopped, a 
tampon of cotton and gauze, saturated with one of the prep- 
arations of glycerin, will prolong the depletion. A tampon 
raises the uterus to a higher level and improves its circulation, 
while, medicated with glycerin, it has a depletive or cholagogue 
effect upon the vessels of the cervix, causing a profuse watery 
discharge. The patient may be instructed how to introduce 
these tampons, and may use them daily. A tampon saturated 
with a 50 per cent, solution of boroglycerid in glycerin, a 10 
to 20 per cent, solution of ichthyol in glycerin, or carbolic acid 
(i : 16) may be kept in place for one to tw^o days. A tampon 
anointed with one part of ichthyol to four of lanolin is valuable 
when more or less irritation of the vagina is associated with 
the uterine lesion. In laceration of the cervix, where it has 
subsequently become hypertrophied, Emmet's operation is of 
service in relicAdng the congestion and promoting involution 
of the organ. If the cervical mucous membrane is much everted, 
with papillary projections and eroded surfaces, amputation 
of the cervix by the single -flap method advocated by Schroder 
(Section 336) will be more effective. Any disturbances of 
menstruation, such as dysmenorrhea and menorrhagia, should 
receive treatment suitable for endometritis. (Section 434-) 
For this condition, as well as for the chronic metritis, dilatation 
and curetage of the uterus are of value. The dilatation is pref- 
erably done with Pratt's dilators, as these instruments gradually 
stretch the uterine canal without danger of tearing, unless 
the dilatation is excessive, which may occur in the use of the 
parallel-bar dilators. 

After preparation of the patient (Section 181) she is placed 
upon her back, the uterus is exposed by the Edebohls speculum, 
"the cervix is seized and fixed with a double tenaculum, prefer- 
ably with two, when there will be no tearing out under the strain 
of dilatation, and the bougies are introduced, thus gradually 
dilating the cervical canal. The dilatation is followed by the 
use of the curet. This instrument may be blunt or sharp; 
the latter is preferable, if carefully used. The handle of the in- 
strument should be perforated, so that the surfaces can be irri- 
gated as the cureting is done. The instrument is held lightly 



INFLAMAIATIONS. 



409 



between the thumb and finger, and is passed into the uterus and 
drawn down on all sides of the organ in long sweeps, paying par- 
ticular attention to the angles of the body and to the orifices of 
the Fallopian tubes. The use of the curet in this manner does 
not remove the entire mucous membrane; even though it did, 
the mucous membrane would be regenerated from the portion of 
the glandular structure which penetrates the muscular wall. 
The curetage may be followed by swabbing out the cavity of the 
uterus with tincture of iodin, with a combination of tincture 
of iodin and carbolic acid, perchlorid of iron, or preferably 
a saturated solution of iodoform in ether. When any of these 
agents, except the last, are used, the irrigator should be in- 
troduced, again washing out the cavity of the organ, thus 




Fig. 304. — Uterus Dilated with Graduated Bougies. 



removing any clots and superfluous medicine. If the discharge 
of blood is slight, the uterine cavity need not be packed. If 
there is considerable discharge, it should preferably be packed 
with iodoform gauze. Gauze packing is serviceable in that it 
first acts as a tampon, decreasing the danger of bleeding or 
of the formation of a clot of blood, which might become in- 
fected and give rise to extension of inflammation to surround- 
ing structures. Second, by its pressure upon the surface it 
favors the throwing-out of exudation and shuts off the en- 
trance of septic material into the uterine sinuses; third, by 
its capillary action it affords a limited amount of drainage; 
fourth, by its presence as a foreign body it stimulates uterine 
contraction and facilitates the process of involution. The 



410 



GYNECOLOGY. 



vagina is carefully cleansed and a gauze pad is placed within 
it, thus raising up the uterus. This gauze dressing may be per- 
mitted to remain two or three days. After its removal the 
vagina should be irrigated once or twice daily with a bichlorid 
or formalin solution. When the uterine cavity has been the 
seat of extensive inflammation, with a predisposition to hem- 
orrhage, the removal of the gauze may be subsequently fol- 
lowed by uterine irrigation through a double-current catheter. 
In hydrorrhea or pyometra in the aged it is very important 
to make sure that drainage is complete. The accumulation 
of fluid within the uterine cavity results in the formation of 




^i§- 305.— Uterine Cavity Packed with Gauze after Dilatation. 



a sac of this organ, the contents of which may become infected 
and produce an occasional profuse discharge, which may cause 
the greatest alarm on the part of the patient. Drainage in 
such cases should be insured — when necessary, by the intro- 
duction of a drainage-tube, through which the cavity is well 
irrigated and cleansed. Remedies should be applied to the 
uterine cavity which will establish a healthy inflammation 
and arrest the abnormal accumulation. When the uterus 
is displaced, associated with hydrometra or pyometra which 
a pessary fails to correct, the advisability of extirpation of 
the uterus should be considered, particularly if the woman 
has passed the climacteric. Uterine adhesions or peri -uterine 



INFLAMMATIONS. 411 

inflammation need not necessarily contraindicate curetage, 
as not infrequently the increased drainage thus secured will 
result in the relief of the peri-uterine disease. In patients 
who have suffered for a great length of time, who have become 
exceedingly nervous, hysteric, with general health destroyed, 
suffering from delusions or illusions, exceedingly irritable tem- 
per, a source of worry and distress to the family and to them- 
selves, no better plan of treatment can be instituted than that 
advocated by Weir Mitchell as proper for neurasthenic patients. 
This treatment consists in placing the patient in bed; at first 
upon a distinct milk diet, with careful regulation of the bowels, 
correction of disordered condition of the alimentary canal; 
and, later, forced feeding, with as large a quantity of food 
as the patient can properly digest. She is under the control 
of a discreet, careful nurse, who allows her to take no exercise — 
nor even to move without assistance. In place of exercise 
she is given, once daily, thorough massage, thus carrying for- 
ward the blood-current, stimulating the absorption of waste 
material, and causing the introduction into the uttermost 
parts of the body of blood containing oxygen. The anemia 
which characterizes such patients is thus rapidly overcome, 
the number of red blood-corpuscles greatly increases, while 
the elimination of waste material is promoted. Once a day 
she is given an application of the faradic current — general 
faradization. She is isolated from the members of her family, 
and during this period of isolation is brought under careful 
mental discipline, which aims to stimulate her ambition, to over- 
come the condition to which she has become subjected, so 
that by the end of six weeks or two months the patient under- 
goes a complete physical and mental change. 

452. Inflammation of the Fallopian Tube. — Inflammation 
of the tubes is a frequent result of infection, and the gravity 
of the physical changes is directly in proportion to the viru- 
lence • of the poison. Gonorrhea and sepsis are the most fre- 
quent forms of infection which invade these organs. The 
invasion may occur through the uterus by the continuous 
mucous membrane, or through the blood-vessels or lymphatics, 
the former being the more frequent. The inflammation may 
involve the mucous membrane, the muscular w^all, and even 
the peritoneum. It may be catarrhal or suppurative. Gon- 
orrheal infection, most frequently reaches the tube by the 
continuous mucous membrane of the uterine body, and is more 
prone to involve the tubal mucosa, resulting in either catarrhal 
or suppurative salpingitis. It may, however, pass rapidly 
over the surface epithelium into the deeper structures of the 
tube, and causes profound destruction. Other avenues for the 



412 



GYNECOLOGY. 



entrance of infection are an inflamed or diseased appendix, es- 
pecially upon the right side, through adhesions to a knuckle of 
intestine, especially where the tube contains a collection of 
blood, and, finally, through the peritoneum, in which case, how- 
ever, the infection is generally tubercular. The entrance of 
infection into the tube is foUoAved sooner or later by evidences 
of inflammation. The epithelium becomes swollen, edematous, 
and granular, with the infiltration of inflammatory materials 
into the deeper layers. Serous effusion takes place into the tubal 
canal. (Fig. 306.) Loss of the cilia from the epithelium also 












Fig. 306. — -Acute Salpingitis. 
a. Swollen and edematous fold. h. Inflammatory exudate 



vessel, d. Desquamation of epithelium. 
Disintegration of longitudinal fold. 



c. Dilated blood- 
. Infiltration of leukocytes. /. 



occurs, especially upon the free surface, while they may be re- 
tained upon that portion between the folds. The epithelium 
will be found well preserved upon the surface of the tubal mucous 
membrane even when suppurative processes exist. (Fig. 307.) 
The irritating discharge from the tube early leads to irritation of 
the peritoneum and agglutination at the abdominal end of 
the tube, while the swollen structures obstruct the uterine 
orifice. The exudate which collects in the tube may be serous 
or purulent, according to the virulency of the infection and 
the resistive force of the patient. In either case the exudation 
is likely to increase, forming a clear serous collection in the 



INFLAMMATIONS. 



413 



one case, which is known as hydrosalpinx or sactosalpinx, 
while the more virulent process (Fig. 308), which results in a 
more or less extensive pus-collection, is called a pyosalpinx. 




Fig. 307. — Chronic Salpingitis showing Agglutination of Folds. 

a. Union of folds forming gland-like areas, b. Thickened and retracted fold. 

c. Desquamation of epithelium, d. Hyperplasia of tubal wall. 




Fig. 308. — Extensive Pus-collections with General Adhesions. 



414 



GYNECOLOGY 



(Fig. 309.) Occasionally the excessive hyperemia or a partial 
twisting of the base may cause rupture of the blood-vessels 
with an intratubular accumulation of blood. This condition 
is denominated hematosalpinx. The latter condition, how- 
ever, is more frequently associated with the retrogressive pro- 
cesses of ectopic gestation. As a result of the inflammatory 
process the tube ma}'" assume the form of a simple sac, which 
gradualhr becomes distended until it attains a large size, and 

presents as a thin-walled 
cystic tumor. If the peri- 
toneal w^all has not been 
involved, the tumor may 
remain freely movable, 
whether it contain serum 
or pus. Such a sac may, oc- 
casionally, become twisted 
upon itself until the venous 
circulation is partially or 
completely obstructed, and 
then rapid increase in size 
results from the hemor- 
rhage, which takes place 
not only into the sac, but 
also, occasionally, into the 
peritoneal cavity. A young 
girl recently came under my 
observation in whom there 
had been an apparent acute 
exacerbation. Examina- 
tion revealed a large mass 
upon either side, that on 
the left side being situated 
above the uterus, and that 
on the right posterior to and 
below the fundus. An op- 
eration was advised and 
subsequently performed. 
This revealed so much blood 
as soon as the abdomen was opened as to arouse the suspicion 
of an ectopic gestation. The hemorrhage in this patient came 
from the tumor of the left tube, the neck of which was twisted 
near the uterus. The tubal sac was dark (Fig. 312), and covered 
with clotted blood, which also filled that side of the pelvis. 
The right sac was clear and free from blood. Both sacs were 
found to contain pus, the left being mixed with blood. Both 
tubes were free from adhesions. Sometimes the distention of 




Fig. 309. — P3'osalpinx. 



INFLAMMATIONS. 



415 



h - 



'^2 



^} 



the tubal sac overcomes the swelling of the mucous membrane 
of the uterine end, and, therefore, its opening remains patulous 

and permits its 
contents to es- 
cape, after which 
the sac attains 
a favorable posi- 
tion. Such a con- 
dition may lead 
to occasional dis- 
charges of a 
considerable 
quantity of fluid 
through the uter- 
us, giving rise to 
the phenomenon 
'Z^ known as hy- 

drops tubas pro- 
>"*- fluens, or inter- 

•5 mittent hydro- 
^^^ ,^. T~^ salpinx. Inflam- 



— b 



7r 



t^ 



-•i 







7^ 



Fig. 310. — Section from Wall of Pus-tube. 

, a. Folds matted together forming gland-like 
spaces, h, h. Folds undergoing dissolution, c. 
Shows complete desquamation of epithelium 
covering folds. d, d. Blood-vessels distended 
with blood-cells, e. Leukocytic infiltration. 



Fig. 311. — Single Fold 
from Wall of Pus- 
tube, enlarged. Line 
through upper por- 
tion shows area of 
extensive hypere- 



mation of the tube involving its muscular wall causes a shortening 
of its longitudinal muscular fibers, which, owing to the mobility 
of the subserosa, permits the fimbria to be drawn into the 



416 



GYNECOLOGY. 



tube and the peritoneum to be pushed over it like the pre- 
puce over the glans penis in phimosis. (Fig. 313.) The peri- 
toneal edges coming in contact are agglutinated, and the tube is 
sealed up. If the fimbrice are not completely withdrawn, the 
protruding fimbriae may serve as an avenue for leakage in sub- 
sequent distention of the sac and thus cause recurring attacks 

of localized peritonitis. 
^m^^SS^ (Fig. 314.) 

The tubal inflam- 
mation, instead of 
forming the cystic 
tumor already des- 
cribed, may result in 
extensive small-cell in- 
filtration and thicken- 
ing of the longitudinal 
folds, which necessa- 
rily decreases the cali- 
ber of the tube. Fur- 
thermore, in places the 
edges of the folds lose 
their epithelium, be- 
come more or less 
adherent, and upon 
microscopic section 
present the appearance 
of distended glands. 
Such a condition has 
been called salpingitis 
cysto-adenosa, but this 
term, like salpingitis 
follicularis, pachysal- 
pingitis, and other 
designations, is an un- 
necessary distinction. 
The inflammatory in- 
filtration frequently 
involves the folds and 
wall of the tube, pro- 
ducing such hyperplasia of these structures as almost to obliterate 
the tubal canal and to form a large sclerosed mass. The contrac- 
tion of the circular fibers may cause the formation of a series of 
small sacs, each one of which is independent of the other, and 
for which the only relief is afforded by the extirpation of the tube. 
In the more virulent forms of infection the peritoneal surface 
of the tube becomes involved by an extension through its ab- 




Fig. 312. — Distended Pus-tubes Removed from 

Young Girl. 
A. Tube whose pedicle was twisted. Sac filled 

with blood and pus, B. Right tube filled 

with pus. 



INFLAMMATIONS. 



417 



dominal end or through its walls, and extensive adhesions unite 
the organ to coils of the intestine, the uterus, the ovary, or the 
pelvic peritoneum. The enlarged and swollen tube drops down 
into the retro-uterine culde- 
sac, and generally becomes 
adherent to the sigmoid 
flexure or side of the rec- 
tum. As the sac becomes 
more and more distended 
the union thus formed may 
permit the establishment 
of a communication with 
the lumen of the bowel, 
through which the tubal 
abscess drains. The tube 
of one side, dropping into 
the pelvis, may become 
adherent to the extremity 
of the other and form a 

common pus cavity, which may attain a large size. (Fig. 315.) 
By a rupture of the tube, infection of Douglas' pouch may occur, 
thus filling the entire pelvis with a walled-off abscess. The 
intimate association of the abdominal orifice of the tube with the 




Fig. 3^3- 



-Convoluted Fallopian Tube from 
Perisalpingitis. 




Fig- 314- 



-Incomplete Inflammatory Closure of the Fallopian Tube, 
of Fimbrise Unretracted. 



Portions 



ovary causes frequent adhesions between these organs, result- 
ing in intimate fusion of the involved structures, and rendering 
it sometimes difficult to differentiate between the two organs. 

27 



418 



GYNECOLOGY. 



Occasionally they appear as a tubo-ovarian tumor or a fused 
inflammatory mass, which may contain serous fluid or pus. 

453. Symptoms. — Tubal inflammation has no characteristic 
symptoms. If a patient has had an acute pelvic inflammation, 
characterized by extreme tenderness in either pelvic region, 
and aggravated by motion, it is justiflable to conclude that 
the possible pelvic peritonitis has had its origin in a tubal in- 
flammation. When each menstrual period is followed by 




Fig. 315. — Double Tubo-ovarian Collection. 



pain and tenderness in the inguinal regions, tubal inflammation 
is very probable. A normal tube is not usually palpable. In 
diseased conditions, however, especially when the tube has 
become thickened by salpingitis or parenchymatous inflam- 
mation, it may be recognized as a more or less thickened cord 
which slips under the finger and is quite sensitive. When 
hyperplasia of its connective tissue occurs, the tube is felt as a 



INFLAMMATIONS. 419 

contracted, distorted, nodular mass, closely associated with 
the uterus and frequently firmh^ fixed in the pelvis. When the 
abdominal end is closed, it may present an enlargement increas- 
ing from the uterus outward, something like a bell-retort or 
gourd in shape, or resembling a sweet potato or sausage or 
sausage-like links. 

454. Diagnosis. — When the uterus is bound down, with evi- 
dence of extensive peritoneal inflammation upon either side of the 
pelvis, in the majority of cases the tubes will be found to have 
been the source through which the infection has reached the 
peritoneum. In a normal condition, unless the patient is 
very thin, the tubes are not palpable. Inflammatory change, 
however, which renders the tubes resistant and causes them to 
be stiffened, leads to their recognition, so the determination of a 
cord-like structure running out from the side of the uterus is evi- 
dence of tubal inflammation. Where the tubes become occluded 
at their abdominal ends and filled with secretion, they become 
more and more retort- 
shaped, being larger at 
the external portion and 
narrowing toward the 
uterus. A tumor pre- 
senting such a shape as 
this, and quite movable, 
is most frequently a hy- 
drosalpinx. (Fig. 316.) 
It is true that pus-tubes 
may at times be free from Fig. 3 1 6 .—Hydrosalpinx, 

adhesions, but in the 

majority of cases the infection which is so virulent as to lead 
to the formation of pus causes a perisalpingitis, which leads 
to agglutination of the surrounding structures, and not infre- 
quently to absolute fixation of the pelvic structures. Where 
the tube is free from adhesions, it is likety to drop into Douglas' 
pouch. Here the change in the circulation not infrequently 
leads to it becoming adherent to the posterior surface of the 
uterus, the sides of the rectum, or the ovary and tube of the 
opposite side, forming a large mass filling up the pelvis. (Fig. 
315.) These conditions are readily recognized by bimanual 
palpation. In practising this procedure, however, it is very 
important that it should be done with great precaution, re- 
membering that not infrequently these sacs may be so thinned 
that undue pressure may lead to their rupture with the escape 
of their contents into the peritoneal cavity, causing a general 
infection, to be followed subsequently by peritonitis. The 
association of the ovary in a mass of this kind, forming a tubo- 




420 



GYNECOLOGY. 



ovarian abscess, is not always readily recognized. A tubo- 
ovarian cyst is more readily determined by the increase in 
size, by the greater spherical character of the external end of 
the sac, associated with a bell or retort -like shape as we ap- 
proach the uterus. 

455. Prognosis. — Tubal inflammation should always be con- 
sidered a source of danger. Even its mildest forms should 
necessitate resort to treatment, in order, if possible, to arrest 




Fig. 317. — Double Pyosalpinx, Showing Adhesions to the Rectum, to the Uterus, 
and, on the Right, to the Appendix. 

the progress and limit the extension of the inflammation. When 
associated with pelvic peritonitis, the extensive infection, 
especially the streptococcic form, is one of the most dangerous 
lesions with w^hich we have to deal. When associated with 
disease of the ovaries and extensive suppuration of the tube, 
the cure of the patient, in the sense of restoration of her func- 
tions, is absolutely impossible. While the patient may recover 
her health and comfort, she is subsequently crippled for life, 
because her powers of procreation are destroyed. 



INFLAMMATIONS. 421 

Treatment. — (See Section 459.) 

456. Inflammation of the Ovary. — Inflammation of the 
ovary occurs in two forms: oophoritis, inflammation of the 
structure of the organ; peri-oophoritis, where the inflammation 
is confined to its surface. A hyperemia or congestion of the 
ovary may arise as a result of infection. This may be so ag- 
gravated as to lead to rupture of vessels. The occurrence of 
hemorrhage into the structure of the ovary produces small 
collections of blood-clots in the organ, known as ovarian apo- 
plexy, or a large collection of blood, an ovarian hema- 
toma. The latter may destroy the ovary and even rupture 
its coat, and result in a serious internal hemorrhage. Oopho- 
ritis is an interstitial inflammation of the ovary, which may 
be either acute or chronic, septic or gonorrheal. It is char- 
acterized by all the signs of inflammation, hyperemia, swell- 
ing, increase in size of the vessels, extravasation of blood, and 
later pus-formation. The latter may involve only a small 
portion of the ovary or the entire organ may become the seat 
of an abscess. The origin of the infection not infrequently 
arises in a corpus luteum, so we have what are known as corpus 
luteum abscesses. In these cases the walls of the abscess may 
be recognized by the wavy elevations of the inner wall on micro- 
scopic section. The acute form of the disease is most frequently 
the result of infection ; the latter gains admission through lesions 
of the vagina, of the uterus subsequent to labor or abortion, sur- 
gical operations, or an accidental injury. Infection may reach 
the ovary through the continuous mucous membrane of the 
tube or by way of the lymphatics or blood-vessels. In fatal 
cases the ovary will often be found very much enlarged, soft, 
and sloughing, and containing small extravasations of blood 
or pus, or small collections of pus will be found in the con- 
nective tissue and structure of the ovary, or a single large abscess 
may exist, equal in size to a hen's egg or even larger. The 
larger abscesses may be produced by suppuration of an ovarian 
cyst. Suppurating ovaries generally become adherent to the 
neighboring structure, and, if the walls are thick, the pus may 
remain quiescent, thus being the cause of a chronic state of ill 
health. However, the pus may escape by rupturing into the 
bowel, bladder, or vagina. The cavity thus emptied may 
shrink and ultimately disappear, while a state of chronic ill 
health will still continue. An inflamed or cystic ovary, ad- 
herent to the inflamed tube, frequently loses the intervening 
wall and forms a concavity, which is known as a tubo-ovarian 
cyst or tubo-ovarian abscess. Coalescence of both ovaries 
and tubes in such a sac may result in the formation of a tumor 
which fills up the pelvis. The formation of an abscess in the 



422 * GYNECOLOGY. 

ovary is not always associated with peri-oophoritis. Some years 
ago I saw a patient in consultation, and subsequently operated 
upon her, in whom, some three weeks folloAving her delivery, 
her temperature rose to 104° F. Careful examination failed 
to reveal any increase in the size of the uterus or anything to 
indicate that the uterus was the seat of disease. Some en- 
largement of the ovary upon the left side, which, however, was 
free from adhesions, led me to open the abdomen. After enter- 
ing the abdominal cavity the left ovary w^as found the size of 
a small orange ; it was free from any adhesions, but had a small 
flake of lymph on one side, which corresponded to a similar 
flake in the orifice of the tube. The tube itself was not enlarged 
nor did it show any signs of an inflammatory condition. The 
ovary was afterward removed and, when opened, contained 
within a thin shell some thick, greenish pus. The subsequent 
convalescence of the patient was uninterrupted. In chronic 
oophoritis there is a great increase in the connective tissue, 
which results in contraction and thus causes destruction of 
the follicles and compression and arrest of development of the 
stroma, while the epithelium of the free surface is the longest 
preserved. This may present extensive fissures, the result 
of the contraction. In chronic inflammation the tunica albu- 
ginea becomes greatly thickened, so it does not readily rup- 
ture with the development of the Graafian follicle. The con- 
sequence is that the follicle increases in size, and such an ovary 
may present a large number of cysts, producing the condition 
known as cystic degeneration of the ovary. Another form 
of chronic inflammation of the ovary has been denominated 
oophoritis serosa. In this form the inflammation is chronic 
in development and duration, and in the majority of cases it is 
curable if properly treated. It may be a sequel of fevers, 
sometimes it is associated with mumps, and it may follow 
a passive gonorrheal infection. The ovaries become swollen, 
exceedingly tender, and frequently prolapsed. In advanced 
cases they are greatly swollen, quite smooth, shiny, and almost 
translucent. Folds and cicatrices are completely obliterated. 
Cirrhosis is a term which has been applied to various changes 
in the ovary. I have frequently seen ovaries which were pro- 
nounced cirrhotic, but which I could not regard otherwise 
than as physiologic. The term is only applicable to those 
cases in which the ovary has undergone contraction to such a 
degree as to result in the destruction of its glandular tissue 
and decided decrease in size of the organs. 

Peri-oophoritis is a condition characterized by the deposition 
of inflammatory material upon the surface of the ovary. The 
surface epithelium is destroyed and it is likely to be followed 



INFLAMMATIONS, 



423 



by a true oophoritis. This condition, hke simple oophoritis, 
is frequently a part of a widely extended inflammatory process, 
which may involve uterus, oviducts, ovaries, pelvic peritoneum, 
and cellular tissue. (Fig. 318.) It is generally consequent upon 
an extension of infection from the tubal orifice to the pelvic 
peritoneum, although it may follow an abscess of the ovary. 
The end of the tube is usually associated with the ovary in 
this form of inflammation, and it may be the forerunner of a 
tubo-ovarian abscess. The inflammation varies from a few 
bands of adhesions which bind down the ovary and tubal orifice, 
possibly occluding the latter, to a mass of exudation which 




Fig. 318. — Peri-oophoritis. Tube and Ovary Encysted. 



completely obscures both and forms so intimate a fusion as to 
render difficult the line of demarcation between these organs. 
The chief function of the ovary, apart from any supposed 
internal secretion, is to provide a site for the perfect develop- 
micnt and maintenance of healthy ova, and to permit them, 
under circumstances as 3^et undetermined, to pass into the 
mouth of the oviduct. Peri-oophoritis necessarily interferes 
with this process, by the presence of adhesions about the ovary 
or the consequent induration of its tunic. An ovum escap- 
ing from a matured Graafian follicle will be barred from en- 
trance into the oviduct by adhesions which fix the fimbriated 
orifice or so envelop the ovary as to prevent it reaching the 
oviduct. Such adhesions are a cause of severe suftering, espe- 
cially when they limit the free mobility of the ovary and fix it 



424. GYNECOLOGY. 

subject to pressure, as behind the uterus or over the rectum, or 
where intestinal adhesions subject it constantly to dragging and 
tension by intestinal peristalsis. An ovary fixed in the retro- 
uterine pouch, with an overlying retro verted uterus, is a con- 
stant source of distress. Its position, independent of the ad- 
hesions, causes congestion from the obstructed circulation, while 
the pressure of feces and the impinging male organ during coi- 
tion augment the discomfort. 

457. Symptoms. — Oophoritis exhibits no characteristic symp- 
toms. Even in cases of acute septic poisoning no symptoms 
will be present which can be said to be absolute indications 
of an ovarian lesion. In the less severe form of inflammation 
we may recognize symptoms which we could justly attribute 
to ovarian disease, but they are so intimately associated with 
those caused by disease of the oviducts that it becomes difficult 
to differentiate them. Pain is the only constant s^^mptom 
in all varieties of pelvic inflammation, and the site to which 
it is referred bears no constant relation to the affected organ. 
The entire pelvic region may be the seat of pain, but we are, 
however, unable definitely to distinguish the exact origin of 
pain and say whether it is due to affections of the tube, ovary, 
peritoneum, broad ligament, body of the uterus, cervix, or in- 
dependent of disorder in any of them. We can readily appreciate 
this when we remember that the nervous distribution of the vari- 
ous organs is derived from a common sympathetic center. As 
in any inflammatory condition, pain is aggravated by pressure, 
so in inflammatory processes of the pelvic structures pain is 
magnifled by pressure and motion. The pain is distinguished 
from that of true dysmenorrhea by the fact that it is an exagger- 
ation of the distress and is felt between the periods, while true dys- 
menorrhea is purely a menstrual pain. Not infrequently patients 
will assure us that the only time they are free from discomfort is 
during the menstrual flow. Pain may persist subsequent to coi- 
tion as a result of congestive tension. When produced by intra- 
abdominal pressure and increased by standing, pain is greatly 
relieved by assuming the recumbent position. Ovarian pain is 
directly aggrav^ated by pressure over the organs through the va- 
gina or rectum, as during coitus, an examination, or the passage 
of large fecal masses. The various symptoms of pelvic disease, 
such as amenorrhea, menorrhagia, or leukorrhea, are not char- 
acteristic of oophoritis. Peri-oophoritis causes pain which is 
more or less distinctly localized at the pelvic brim, and extends 
down the thigh of the affected side. Not infrequently pain 
is experienced in the corresponding breast. The inflammation 
may extend from the surface of the ovary into its substance 
and cause changes in its stroma, dropsy of its follicles, or hem- 



INFLAMMATIONS. 425 

orrhage, producing a condition, in the one case, known as cystic 
degeneration of the ovary, and, in the other, as ovarian hema- 
toma or ovarian apoplexy. The wide distribution of neurotic 
symptoms must not be overlooked. The local pelvic lesion 
may be a minor one. To oophoritis or uterine displacement 
are often attributed symptoms which are the result of fissures 
of the cervix, mobility of the kidney, enteroptosis, gastroptosis, 
or even central lesions of the nervous system, which will per- 
sist after the supposed local lesion has been cured or removed. 
Such experiences are a source of great disappointment to the 
medical practitioner. At times relief is obtained, at others 
pain and distress continue or are even aggravated. 

458. Diagnosis. — Inflammatory processes of the ovary do not 
present a constant characteristic clinical picture. The infection 
rarely confines itself to the ovary, consequently the sympto- 
matic phenomena are modified by the circumjacent inflamma- 
tory changes. The recognition of a tender body, somewhat 
enlarged, yet retaining the shape of the ovary, by vaginal or rec- 
tal palpation, adds certainty to the diagnosis. The presence of 
adhesions or exudate will render its determination difficult 
and make it doubtful how much the swelling is due to the 
ovary, the tube, or the exudate. In acute conditions or in 
hyperesthetic patients an anesthetic will prove of value. 
Where the obscurity of the condition can not be overcome, a 
preliminary vaginal or abdominal incision may be necessary in 
order to determine the proper operative procedure. 

459. Treatment of Inflammation of the Appendages. — In 
the great majority of chronic inflammations of the uterine 
appendages the treatment of diseased conditions of the tubes 
is similar to that of diseases of the ovaries, or, in other words, 
the tw^o conditions are so closely related that I deem it better to 
consider their treatment under the one section. The first aim in 
the treatment should be the preservation of the function of the 
affected organs. The second, the restoration of health to the 
patient. Treatment may be either medical or surgical. The 
medical or nonoperative treatment consists in rest in bed and 
in keeping the patient absolutely quiet. Free purgation should 
be established by the use of salines in order to make the in- 
testines drain the peritoneal cavity and relieve the congestion. 
The diet should be restricted and cold should be applied to 
the external surface. In the acute stage the application of 
cold in the form of the ice-bag is of value, and this should be 
kept more or less continuously applied. The ice-bag decreases 
the congestion, limits the exudation, lessens the danger of 
suppuration, and promotes absorption, xlfter the more acute 
symptoms have subsided the treatment may still further be 



426, GYNECOLOGY. 

promoted by the application of pressure, using three to five 
pounds of shot in a bag, which is appHed over the inflamed, 
indurated tissues; the pressure is increased and its position 
changed as the condition may demand. Unless suppuration 
has occurred, resolution will probably be accomplished. The 
absorption may be still further promoted by the use of counter- 
irritants, such as small blisters, painting with iodin, the use 
of croton oil, or inunctions of dilute ointment of the iodid of 
mercury or a dram of the official ointment to an ounce of lanolin. 
Occasionally ice will be very uncomfortable to the patient, while 
heat will be more grateful. A flaxseed poultice may be ap- 
plied, or, what is probably much more agreeable to the patient 
and more easily applied, would be to take a piece of spongio- 
pilin, wring it out of hot water, and place it over the abdomen, 
and over this a dry cloth. This should be changed as frequently 
as may be necessary. The changing may be made less frequent, 
however, by the application over it of a hot-water bottle. Ich- 
thyol in lanolin, one or two drams to the ounce, may be rubbed 
into the lower part of the abdomen, and this supplemented 
by the pressure already suggested. Hot vaginal douches 
should be employed, and benefit will frequently be obtained 
from the use of hot rectal enemas, using a pint to a quart of hot 
water and directing the patient to retain it as long as possible. 
This is more eft'ective than hot vaginal douches, for the reason 
that the heat comes more nearly in contact with the infiamed 
surfaces and can be retained for a greater length of time. In- 
ternal medication during this time, aside from the application 
mentioned, should be largely supporting. The patient should 
be carefully protected from any possibility of exposure or 
overfatigue. During the menstrual period it is preferable 
that the patient should be confined to bed. The more acute 
stages having subsided, in addition to the douches and enemas 
recommended the patient ma}^ take a hot sitz-bath for fifteen 
to thirty minutes daily. With the further subsidence of the 
acute symptoms and in those cases in which it is evident that 
suppuration has not occurred, the adhesions binding down 
the ovaries and tubes may be overcome by the employment 
of pelvic massage. The structures are lifted up with one or 
two fingers within the vagina and manipulation over the ab- 
domen employed, gradually pressing the fingers in so as to 
follow lines of cleavage and to lengthen the bands of adhesions 
or promote their absorption by stretching and irritation. The 
congestion and pain in chronic inflammation of the ovary may 
frequently be very greatly lessened by the administration 
of fluidextract of gelsemium, giving five drops three times 
daily. In these conditions great prudence must be exercised 



INFLAMMATIONS. 427 

in the administration of anodynes. A patient suffering from 
pelvic pain as a result of attacks of peritonitis, with binding 
down of the pelvic viscera, may very easily be led into the 
habit of taking morphin or opium until, instead of it simply 
being a servant, it attains the position of master, and the patient 
finds herself enslaved to a drug from which emancipation is 
very difficult. While it may be necessary, in an acute attack, 
to administer a dose of morphin in order to allay the violent 
pain, yet, in the majority of cases, the early and continuous 
administration of salines, associated with the application of 
the ice-bag, will be effective in arresting the severe pain, or 
at least in making it endurable. The measures Avhich we have 
already discussed are in the line of what we have denominated 
the first aim in the treatment of lesions of the uterine appen- 
dages — that is, to maintain the functions of these organs. 

Surgical Treatment. — The surgical treatment does not neces- 
sarily exclude the object which Ave have considered as the first 
aim in treatment, but may, indeed, assure its accomplishment, 
especially when early and efficiently established. Delay, how- 
ever, would almost certainly favor the development of conditions 
which would necessitate more serious procedures. Operative 
treatment, with a view to maintenance or restoration of func- 
tion, is known as conservative treatment. AVhere the sacrifice 
of the appendages is considered necessary, in order to save 
life or insure good health, the procedure is known as a radical 
one. Conservative treatment may consist in the breaking 
up of adhesions, the reopening of the orifice of the tube, sal- 
pingostomy, or the partial resection of the tube itself, thus 
shortening it and permitting the removal of those portions 
which are prejudicial to health. (Figs. '319 and 320.) This 
procedure also comprises the resection and removal of any 
diseased portion of the ovary, with the endeavor to retain a 
sufficient portion of the organ to insure the continuance of 
ovulation and menstruation. In chronic oophoritis with marked 
thickening of the tunica albuginea and the development of 
small cysts in the ovary, a resection of the ovar}^ or removal 
of the more diseased portion will frequently result in such 
metabolism as to restore the remaining portion of the ovary 
to a more normal condition. Wherever conditions will permit, 
a portion of the ovary should be retained; its retention will 
insure the continuation of menstruation and ovulation and 
have a marked influence upon the general morale and nervous 
condition of the patient. The retention of the whole or a 
part of the ovary is desirable even though it may be necessary 
to remove both tubes, because it insures the continuation of 
ovulation and menstruation. This has a marked influence 



428 



GYNECOLOGY. 



Upon the nervous system of the patient. In surgical opera- 
tions we are obHged to be governed by the physical condition 
of the organs under consideration. The abdomen should not 
be opened unless palpable disease of the uterine appendages 
by physical examination can be determined. Operations for 



• tube: 




OVAR^ 




:W-, 



Fig, 319. — Resection of Tube. 




Fig. 320. — Operation of Resection of Tube Completed. 

pain in the region of the ovary, without ovarian enlargement, 
will most frequently be attended with no favorable result. 
Where the disease is extensive and ovaries and tubes have 
undergone destruction, the removal of these organs will often- 
times be the only procedure that will afford any hope for res- 
toration of the comfort and health of the patient. In sup- 



INFLAMMATIONS. 429 

purative conditions where the ovary is also involved in the 
inflammatory process the better plan of procedure will be 
the removal of the ovary and tube complete. In a patient 
upon whom I recently had to operate the left ovary and tube 
were so extensively involved that their removal was indicated. 
The right tube was considerably enlarged, its wall was several 
times its ordinary thickness, and the cavity of the tube contained 
pus. In this case, the left tube and ovary having been re- 
moved, the right tube was dissected out from the cornua of 
the uterus and the opening in the broad ligament was closed 
with a continuous catgut suture, thus controlling hemorrhage. 
The ovary, as it presented no marked abnormal change, was 
permitted to remain. In these cases the operation is some- 
times exceedingly difficult, as on opening the abdomen we 
will find the tube and ovary, with the fundus of the uterus, 
matted down in the pelvis in close association with coils of 
intestine, the omentum, and the parietal peritoneum. Where 
the condition is one of recent sepsis, it may sometimes be neces- 
sary to consider the advisability of removal of the uterus as 
well as of the appendages. When there is occasion to open 
the abdomen, the structure should be carefully inspected and 
examined by touch. The adhesions should be broken up and 
proper care be exercised to insure control of hemorrhage. In 
some patients the broad ligament will be so contracted from 
the inflammatory changes that we will be unable to lift the 
ovary and tube out of the wound. In such cases the broad 
ligament should be resected with the ovary and tube. This 
may be accomplished without the application of ligature, seiz- 
ing the bleeding vessels as we proceed, and holding them with 
hemostatic forceps, after which the wound in the broad liga- 
ment can be closed with a continuous catgut suture, so intro- 
duced that each turn or second turn shall lock the preceding 
stitch, and thus secure against hemorrhage and prevent the 
broad ligament from being distorted. After operations in some 
of these more critical cases, and sometimes prior to operation, 
the patient may be very greatly benefited by the employment 
of the rest treatment — the plan of treatment introduced by 
S. Weir Mitchell. It consists in the isolation of the patient, 
careful study of her condition, and the improvement of her 
general nutrition. The patient should be kept absolutely in 
bed ; she should have her secretions made normal and her diet 
restricted, possibly at first to milk, and, later, feeding should be 
forced. Graduated exercise should be advised, supplemented 
by the employment of massage and electricity. By these 
means the elements of the blood are restored and the patient 
gradually regains her strength and health. 



430 GYNECOLOGY. 

460. Pelvic Inflammation. — The term pelvic inflammation 
is a comprehensive one. It is necessary, at the outset, to 
limit it to the conditions which we intend it shall include. In- 
flammation of the individual pelvic viscera has been discussed, 
so this term will be confined to inflammation which involves the 
cellular tissue and the peritoneum. It consequently includes those 
affections described as pelvic cellulitis and pelvic peritonitis. 

These conditions have been designated as peri-uterine 
inflammation; by some writers of .distinction, notably Virchow 
and Matthews-Duncan, the terms parametritis and perimetritis 
have been used — the former to indicate inflammation of the 
cellular tissue; the latter, of the peritoneum. These terms are 
objectionable for the following reasons: First, they are so nearly 
alike in sound that it is difficult for the student to avoid confusion 
in their use, and the subject is rendered more difficult of com- 
prehension. Second, a difference in the anatomic relations 
of the peritoneum and cellular tissue to the uterus is implied 
which does not exist. The pelvic connective tissue and the 
pelvic peritoneum are in equally close contact with the uterus. 
It is distinctly objectionable, therefore, to consider one as an 
inflammation around the uterus and the other as an inflamma- 
tion near it. Third, the conditions are described as associated 
with the uterus, while they may exist in all the tissues of the 
pelvis, and are not necessarily uterine in their origin. 

Careful investigation of the pathology of these conditions 
by autopsy, and their more extended study during abdominal 
procedures while in active stages of disease, have demonstrated 
how easily such erroneous views could arise. 

Bernutz and Aran, of France, many years ago demonstrated 
the true nature of pelvic inflammation, which has been abun- 
dantly confirmed in the practice of abdominal surgery, where 
the opportunity has been afforded for comparing physical 
signs with the actual existing pathologic changes. 

461. Varieties. — Pelvic inflammation, as we have described 
it, is properly divided into inflammation of the cellular tissue 
(pelvic cellulitis) and inflammation of the peritoneum (pelvic 
peritonitis). It must not be understood in these definitions 
that the demarcation between these aff'ections is sharply de- 
fined, for, in practice, we do not find inflammation confined 
to the single or specific structure. Their use indicates simply 
that the infiammation predominates in the structure named. 

462. Pelvic cellulitis, parametritis, or peri-uterine phlegmon 
is an infiammation of the pelvic cellular tissue. It may be 
either primary or secondary: i. e., it may have originated in 
the cellular tissue or may have reached it by extension from 
the neighboring structures. The primary inflammation is an 



INFLAMMATIONS. 431 

acute infective disease which differs in no respect from acute 
inflammation of the connective tissue in any other portion 
of the body. Chronic pelvic celluHtis is ahvays a secondary 
affection, and may or may not have been preceded by an acute 
attack. The pehdc connective tissue is not a special structure, 
but a portion of that wide system of mesoblastic connective tis- 
sue which surrounds the great vessels of the trunk and accom- 
panies their branches from origin to termination. It is found 
in the pelvis, partly in the form of a loose areolar network, partly 
in the more condensed form of fascia. It surrounds all the blood- 
vessels, nerves, and lymphatics, as well as the uterus, and serves 
as investing sheaths for them outside the pelvic cavity. It is 
closed off from the perineum and ischiorectal fossa by the 
pelvic fascia, a strong aponeurosis, which is attached to the 
pelvic wall between the pubic bones and bodies of the ischia, 
and along that thickening of the obturator fascia known as 
the white line. It passes as a continuous layer over the levator 
ani and coccygeus muscles to the vagina in front, and to the 
rectum and coccyx behind. It closely blends with the vaginal 
orifice, behind the pubic symphysis, as the triangular liga- 
ment. Inflammatory exudations of the female' genital organs 
above the vulva are situated above this strong fascia. The 
cellular area with such a boundar}^ below has the peritoneum 
for its superior limitation. This boundary, however, is less 
abrupt, as it is continuous with the subserous connective tissue 
of the parietal peritoneum of the abdomen. With the ex- 
ception of the fundus of the uterus, it forms a layer beneath 
the entire pelvic peritoneum — both parietal and visceral. The 
so-called uterine ligaments contain more or less of it between 
their peritoneal folds, and in certain situations it is abundant; 
for instance, around the supravaginal portion of the cervix, 
and along the base of the broad ligaments and between the 
bladder and symphysis pubis. In the latter situation it con- 
tains a varying quantity of fat in its meshes. 

Its oflice in the pelvis, as elsewhere, is to protect and sup- 
port the other tissues, performing a passive mechanical function. 
It affords a cushion which prevents injury of the viscera (Schae- 
fer). The connective -tissue layer, between the vagina and 
peritoneum posterior to the uterus, generally does not measure 
more than | of an inch in thickness, but in pregnancy its thick- 
ness is greatly increased. During the progress of develop- 
ment of a pregnant uterus the broad ligaments are gradually 
drawn upward, until at the completion of the pregnancy they 
lie in the iliac fossa, above the brim of the pelvis, while no peri- 
toneum dips into the lateral parts of the pelvis. The space 
thus vacated is filled with connective tissue, which during 



432 GYNECOLOGY. 

the later months of pregnancy is enormously increased. Freund 
describes a form of cellulitis which affects more particularly 
the fat less connective tissue, or fascia, which he calls para- 
metritis chronica atrophicans circumscriptum et diifusum. 
Cellulitis is a very common complication of pelvic peritonitis 
involving particularly the uterosacral ligaments and peritoneal 
folds. Schultze calls this parametritis posterior: uterosacral 
cellulitis is more accurate. Cicatrization of the ligaments follow- 
ing such inflammation causes traction upon the upper part of 
the cervix, and is a very common cause of dysmenorrhea and ster- 
ility. As a result of the contraction of the tissues the uterus 
may be antefiexed and draw^n to one side or backward, thus pro- 
ducing a pathologic anteflexion. By compression of the vessels 
and nerves the uterus and ovaries may become atrophied. 
Cellulitis may exist with or without suppuration. When sup- 
puration does not occur, an exudation results in the connec- 
tive tissue, which becomes edematous, and subsequently more 
or less organized, firm, and hard, causing pressure upon the 
vessels and nerves which pass through it. The changes in 
this structure are similar to those which take place in cirrhosis 
of the liver or of the kidney. 

463. Etiology. — Primary pelvic cellulitis is always a re- 
sult of sepsis. Ready entrance for septic material is afforded 
through lacerations of the cervix uteri. These injuries may 
be caused by the use of forceps, and, if kept aseptic, readily 
heal. In the nullipara cellulitis may arise from the same causes 
as pelvic peritonitis, such as exposure to cold during men- 
struation, being then generally associated with pelvic peri- 
tonitis, and from surgical operations which open the connective 
tissue, as in the removal of large uterine polypi, affording an 
opportunity for cellulitic infection. The danger is especially 
great when the gro\\i;hs are expelled or removed while in a 
state of necrosis. A certain amount of lymphangitis is then 
associated, with which the lymphatic glands may be implicated. 
Cellulitis may develop from disease in the bladder. As a re- 
sult of such irritation thickening occurs in the connective tissue 
outside the bladder, which thickening passes outward and for- 
ward, and in ultimate atrophy may cause uterine displace- 
ment in the opposite direction. From the rectum, the causative 
irritation may be dysenteric. A pelvic cellulitic abscess is 
not infrequently so situated as to render it more than probable 
that the hypogastric glands are involved. Inflammation occurs 
much more rarely in the cellular tissue than in the pelvic peri- 
toneum. With the advent of suppuration an abscess follows, 
which is generally of large dimensions, although occasionally 
several abscesses may be found in close apposition. 



INFLAMMATIONS. 433 

464. Symptoms. — In puerperal cases the cellulitis is gener- 
ally ushered in about the second or third day, with a rigor or 
chill, although it may occasionally occur later. In nonpuer- 
peral cases the interval between infection and the first mani- 
festation of symptoms is rarely more than one or two days. 
The occurrence of the chill has produced the belief that the 
inflammation arises from exposure to cold; simultaneously with 
the chill occurs an elevation of temperature, a rapid pulse, but 
rarely pain, unless the peritoneum is involved. When suppu- 
ration occurs, the most marked symptom is the progressive 
emaciation associated with pallor or earthy sallowness of the 
skin. The skin is harsh, dry, and covered with branny scales 
from the fine desquamation. Peritonitis may complicate the 
condition and will be indicated b}^ the frequent vomiting of 
a dark-green fluid. Vomiting will be excited by the ingestion 
of the smallest quantity of anything, even liquids. The patient 
looks ill, loses her appetite, and suffers from marked debility and 
severe mental depression. She becomes very irritable. If the 
exudation extends to the fascia over the iliacus and psoas 
muscles, and particularly if the connective-tissue elements 
between these muscles are involved, the patient will lie upon 
her back with the leg of the affected side flexed and the thigh 
bent upon the trunk. The symptoms are those of a subacute 
form of septicemia. Pain and local signs may be so slightly 
marked as to lead to the condition being unsuspected or over- 
looked. 

465. Physical Signs. — In the early stages of an acute attack 
the physical signs are but slightly marked. All that will be 
noticed by digital examination is that the vagina is hot and its 
vessels are pulsating. In a few hours there are indications 
of an inflammatory exudate. There is a doughy sensation and 
fullness on one side of the uterus and in the iliac fossa. This 
may extend partly around the cervix, and subsequently become 
hard and indurated. If the poison has entered through a 
wound in the cervix, the latter becomes less movable. The 
supravaginal tissues on the affected side are tender, more or 
less hard, and unyielding. There is a bulging at the side of 
the uterus, and the lateral fornix on that side is apparently 
obliterated. (Fig. 321.) We rarely find both sides of the 
uterus affected at the same time, but occasionally the whole 
supravaginal portion of the cervix may be embedded in a thick 
collar of indurated tissue, which more or less completely sur- 
rounds it. Generally the disease spreads laterally along the 
base of the broad ligament to the tissue beneath the reflection 
of the peritoneum on the anterior abdominal wall. AVhen this 
occurs, a uniform hardness or resistance is felt in the abdominal 

28 



434 



GYNECOLOGY 



wall beneath the muscles. This may assume the form of a 
broad band, from J of an inch to 2 inches or more in width, 
which lies along the upper border of Poupart's ligament. Occa- 
sionally the exudation spreads upward and outward from above 
Poupart's ligament into the iliac fossa. This exudation may 
extend in one of two ways : (a) it follows the course of the lymph- 
atics which run from the uterus outward beneath and be- 
tween the layers of the broad ligament to the glands and lumbar 
region ; (b) by lines of cleavage in the cellular tissue of the pelvis. 
In the latter form it not infrequently passes backward, pro- 
ducing an exudation in the tissue of one or both uterosacral 
ligaments in the tissue surrounding the rectum, and lines the 
posterior pelvic wall beneath the peritoneum. In these cases 




Fig. 321, — Exudation in Broad Ligament from Pelvic Cellulitis. 



the rectum will be felt wholly or partly surrounded by a belt of 
exudation, which forms a bridge or an arch. If suppuration 
does not occur, the exudation becomes absorbed, and in un- 
complicated cases the hardness may so far disappear as to 
leave no subsequent trace. In not a few cases pelvic cellulitis 
results in the formation of an abscess. The situation of the 
abscess and the direction in which it may be expected to extend 
depend upon the situation and the extent of the inflammatory 
exudation. If the inflammation is seated in the base of the 
broad ligament and passes forward beneath the peritoneum, 
where it is reflected on to the anterior abdominal wall, an area 
of induration may be noticed above Poupart's ligament. Sup- 
puration can be recognized by the occurrence, over the indurated 



INFLAMMATIONS. 



435 



area, of edema in the skin, which pits on pressure; by deep- 
seated fluctuation, especially recognized by bimanual examina- 
tion ; and by the eventual pointing of the abscess a little above 
Poupart's ligament. The pus can often be detected before it 
reaches the surface by passing the tip of the finger carefully over 
the induration, when a softened point will be recognized in the 
surrounding hardness. As we have already noticed, pelvic cellu- 
litis may unfortunately extend backward instead of forward, 
when, if suppuration follows, an abscess forms beneath the peri- 
toneum covering the back of the pelvis. Such an abscess has 
no direct access to the free surface, relief is much longer delayed, 
and extensive burrowing follows. It can extend into the ihac 
fossa and the loin, particularly when the posterior wall is the 
seat of the abscess. It 
may point at the iliac 
crest, or may sometimes 
leave the pelvis by the 
sciatic notch and follow 
the course of the sciatic 
or gluteal vessels. Again, 
it appears in Scarpa's 
triangle, having followed 
the side of the femoral 
vessels. By whatever 
route the abscess leaves 
the pelvis it will follow 
the prolongation of the 
connective tissue upon 
the blood-vessels or the 
ureter, rather than that 
of the nerves or tendons. 
When matter burrows 

along the psoas muscle, it comes, not from cellulitic abscess, 
but from dead bone, and this is an important fact to keep in 
mind. 

I saw with the late Dr. Kappes a patient who had been con- 
fined about six weeks previously, and she was suffering from 
what was apparently a subacute attack of septicemia. She 
was lying Avith her limbs drawn up, complaining of severe pain 
in the abdomen, extending into the groin. On examination, 
induration could be recognized extending from the left lumbar 
region into the groin. Vaginal examination disclosed the 
uterus freely movable, with no induration about it nor in the 
pelvis, until the finger was passed well above the brim, when 
the indurated psoas muscle was recognized. On investigating 
the history of this patient it was found that she had suffered 




Fig. 322. — Exudation of Cellulitis over Rec- 
tum, 



436 GYNECOLOGY. 

from a fall about the third month of pregnancy. She was 
walking on stilts in her back yard to amuse her children, when 
she tripped and fell in a sitting position. She suffered more 
or less discomfort during the entire remainder of the pregnancy. 
An incision w^as made on the left side over the crest of the ilium 
and the peritoneum was pushed forward, when the tissue of the 
psoas muscle was found infiltrated with purulent material. It 
was hoped that the vent thus afforded would give the patient 
relief. She improved for a few days, when pain occurred upon 
the opposite side, where a similar condition was found. 

We not infrequently hear of cellulitic abscesses opening 
into the rectum, vagina, or bladder, but these cases, when 
considered in the light of the pathology of pelvic inflamma- 
tion, are doubtful, and are more than likely cases of intra- 
peritoneal suppuration which has originated either in dis- 
ease of the Fallopian tubes or of the ovaries. An abscess will 
usually point between the seventh and twelfth weeks. 

In discussing pelvic disease we should not overlook a peculiar 
malignant form of inflammation, mostly occurring in puer- 
peral women, in which, associated with other lesions significant 
of the virulence of the infection, multiple abscesses in the con- 
nective tissue are found. Many of these abscesses are so small 
as easily to elude detection. The condition is known as diffuse 
pelvic suppuration, and has all the characteristics of phleg- 
monous erysipelas. The tissues become edematous and of 
a livid hue. Suppurating thrombi are found in the veins and 
the lymphatics are acutely inflamed. Occasionally, the ovaries 
may be found in a state of suppuration. Associated with 
this condition are all the symptoms of acute infection in its 
most virulent form. 

466. Diagnosis. — The absence of pain not infrequently 
permits considerable progress before the existence of the con- 
dition is suspected. Puerperal women, because of the tender- 
ness of the external genitals and the presence of the lochial 
discharge, are very averse to vaginal examination. If the 
puerperium pursues a normal course, this aversion should be 
respected, but it can not be too strongly asserted that examina- 
tion should be made whenever symptoms of pyrexia supervene 
and the ordinary course of convalescence is interrupted. A 
temporary disturbance of temperature and of pulse-rate may 
result from such causes as constipation, excitement, and mam- 
mary engorgement. Unless such conditions can be recognized 
as provocative of the disturbance, or if the abnormal symp- 
toms are persistent, and especially if the lochia is offensive, a 
thorough examination not only of the vagina, but of the in- 
terior of the uterus, should be made. During the first ten 



INFLAMMATIONS. 437 

days subsequent to delivery the uterus can be readily explored 
without artificial dilatation. If a portion of placental tissue 
or a decomposing blood-clot is found, it should be removed, 
and the uterine cavity should be cleansed and disinfected. 
Ordinarily the symptoms will be promptly relieved. If they 
are not, the examination will have revealed the probable cause 
of the disorder, and simultaneously will permit any swelling 
or other morbid condition of the pelvic tissues to be detected. 
A few days after the onset of the attack the physical signs 
of cellulitis will be so marked as to render the diagnosis cer- 
tain, and a laceration of the cervix or of the vagina will be 
disclosed as the probable gateway for the entrance of the in- 
fection. Occasionally the first indication of cellulitis will be 
an impaired mobility of the cervix upon one side, on which 
tenderness and, swelling will be marked. Later, this infiamed 
structure becomes stiff, and passes to well-defined hardness. 
The cellulitis may be situated to one side of the cervix or may 
extend along the base of the broad ligament of the aft'ected 
side. The lateral fornix of the vagina will be completely ob- 
literated. When the inflammation extends back\A^ard, vaginal 
examinations of the posterior wall will reveal a diffuse fullness 
and hardness on the affected side, which is still further dem- 
onstrated by rectal examination. In the rare cases in which 
the broad ligament itself is affected the diagnosis is determined 
by finding the mobility of the body of the uterus impaired, 
and a more or less flattened mass of induration upon one side, 
which is continuous with the uterus. Excepting the plane 
of tissue between the cervix uteri and the bladder, the cellular 
area of one side of the pelvis is practically shut off from that 
of the other. Hence, we flnd pelvic cellulitis is, for the most 
part, unilateral. The differential diagnosis of pelvic peritonitis 
will be discussed later. (See Peritonitis.) The only other 
conditions with which cellulitis can be confounded are hematoma 
of the broad ligament and myoma of the uterus. In hematoma 
there is an effusion of blood into the connective tissue, which 
forms a slightly movable, somewhat flattened tumor along- 
side of and continuous with the uterus. The history of the 
case and the absence of symptoms of severe illness will generally 
serve to distinguish it. It occurs suddenly, from rupture 
of a pregnant tube or of a varicose vein in the broad ligament. 
In either case the onset is marked by violent pain, faintness, 
syncope, and usually vomiting. In pregnancy of the tube 
one or two menstrual periods will have been passed, and the 
pain will be situated in the lower part of the abdomen, generally 
on one side, with irregular uterine bleeding. The effect of 
such an outpouring of blood upon the temperature and pulse 



438 GYNECOLOGY. . 

is transient. The temperature is not elevated. If infection 
occurs, suppuration results, and the symptoms then are similar 
to those of pelvic abscess from cellulitis. Myoma can rarely 
be mistaken for cellulitis. Only in those rare cases in which 
the myoma develops laterally between the layers of the broad 
ligament and forms a more or less hard tumor directly con- 
tinuous with it is error possible. Should the myoma be com- 
plicated by a localized peritonitis, or the tumor become in- 
flamed or gangrenous, the diagnosis may be difficult. In the 
posterior wall error is scarcely probable, for large inflammatory 
exudations into the connective tissue behind the uterus are 
extremely rare. In the anterior wall the signs of cellulitic 
exudation between the bladder and the upper part of the cervix 
are well marked and characteristic. 

467. Prognosis. — The disease usually terminates in recovery, 
except in the very diffuse variety, in which it is a part of a 
general septic process. With the subsidence of the fever the 
exudation is gradually absorbed, and under favorable circum- 
stances entirely disappears in a few weeks. Cellulitis un- 
complicated by peritonitis leaves no unpleasant results, no 
adhesions nor displacements. Its existence, consequently, is 
no bar to subsequent pregnancy. If fever continues longer 
than five or six weeks, suppuration has probably resulted. 
The duration and progress of the illness will largely depend 
upon the direction the pus takes. Generally it points above 
Poupart's ligament, where it can be easily and satisfactorily 
opened. Such cases invariably do well. In the rare cases 
when it occurs at the back of the pelvis, pus is longer in reach- 
ing the surface, and may burrow in dift^erent directions. Such 
cases often last a long time, and are likely to be complicated 
by extension to the peritoneum. When resolution and the 
absorption of the inflammatory processes are slow, the exudate 
will become organized, and cause cicatricial contraction and 
resulting displacement of the uterus. Such contractions also 
lead to atrophy of the uterus and ovaries. The obstruction 
of the circulation produces localized congestion and even 
inflammation, and causes disturbances of menstruation, such 
as menorrhagia, dysmenorrhea, and sterility. It is neces- 
sary, then, to be guarded in our promises of complete recovery. 

468. Treatment. — A description of the disease and of its 
causes emphasizes the importance of preventive treatment. 
This consists in careful attention to the principles of asepsis 
or surgical cleanliness in all midwifery cases and in surgical 
manipulations. If freedom from infection could be insured, 
pelvic cellulitis would disappear. When the disease is once 
developed, medication, either internal or external, has but 



INFLAMMATIONS. 439 

little influence. The most important indication is to avoid 
doing the patient harm. Particular care should be exercised 
in the administration of opium and antipyretics. The former 
agent is generally given as a matter of routine. Opium adds 
to the disturbance of the already obstructed digestive functions 
and aggravates one of the difficulties which it is important 
to obviate — viz., constipation. Opium or morphin should 
be given only in cases complicated by peritonitis, in which it is 
absolutely necessary to afford relief. Similarly, antipyretics 
should be reserved for the rare occasions when the temperature 
is so high as to constitute in itself a source of danger. A simple 
saline mixture, potassium citrate, or small, frequently repeated 
doses of magnesium sulphate should be given until the bowels 
are freely evacuated. Care should be exercised to avoid fecal 
accumulation. ■ The question of feeding is of equal impor- 
tance: farinaceous diet in the acute stages, with meat, eggs, 
and easily digested food in the later period of the disease. The 
tendency to emaciation calls for generous feeding. In the 
early stages of the inflammation an ice-bag over the abdomen 
will limit the congestion and the amount of inflammatory 
exudate. When the ice-bag is uncomfortable or causes dis- 
tress, hot fomentations should be applied. Hot vaginal douches, 
at a temperature of from iio° F. to 115° F., are advocated 
by Emmet, although the influence they exert is doubtful. When 
pus forms, the case should be dealt with according to recog- 
nized surgical principles. The abscess should be opened as 
soon as fluctuation is detected or there is the faintest indication 
of pointing, and drainage should be instituted for a few days. 
If the abscess points in the vagina, it must be opened there. 
Most of the fluctuating swellings felt through the vaginal roof 
are not cellulitic abscesses, but come from an entirely different 
direction. While it is not generally recognized as the proper 
plan of treatment, yet, without question, the course of an abscess 
can be shortened or suppuration prevented by making an incision 
into the infected cellular tissue through the vagina as soon as the 
swelling about the uterus can be recognized. The infected area 
should be broken into with the finger, and a gauze drain inserted 
which will afford vent for the discharge. The drainage thus se- 
cured will frequently obviate the occurrence and danger of sup- 
puration and prevent the extension of inflammation to the pelvic 
peritoneum. If the patient lies with the thigh flexed on the 
body, the limb should be exercised by lifting the foot with 
the hand under the heel two or three times a day sufficiently 
to straighten the knee. This will prevent permanent contrac- 
tion and stiffening of the joint. 

Chronic pelvic cellulitis, as already asserted, does not exist 



440 GYNECOLOGY. 

as an independent affection. It not infrequently follows puru- 
lent salpingitis or other intrapelvic suppurative inflammation, 
and involves only the parts immediately contiguous to the in- 
flamed structures. The induration which it causes, for a time, 
of course, introduces an element of obscurity into the diagnosis 
of deep-seated inflammatory lesions of the pelvis. It is rarely 
attended with cellulitic abscess, and is characterized chiefly by 
edema and small-cell infiltration of the connective tissue. Its 
absorption and the mobility of the uterus may be promoted by 
the practice of pelvic massage. (Section 231.) When cellulitis 
has existed sufficiently long to result in atrophy of the uterus or 
ovary, treatment exerts but little effect. 

469. Pelvic peritonitis, perimetritis, perisalpingitis, or peri- 
oophoritis is an inflammation of the peritoneum situated with- 
in the pelvis. It occurs much more frequently than pelvic 
cellulitis; indeed, more frequently than any other form of in- 
flammatory disease within the pelvis. In the great majority 
of cases it is an infective process, due either to the presence 
of micro-organisms or to the effect of their chemic products. 
In the main its action may be regarded as beneficial, it being 
one of nature's efforts to resist or to do battle with the invad- 
ing foe by erecting barriers around the diseased area. These 
barriers serve to narrow or to confine the field of invasion, and 
shield the neighboring structures from damage. Treves asserts 
that the purpose of peritonitis is to save and not to destroy 
life. Unfortunately, the poison may be so virulent, exist in so 
large a quantity, or the resistive powers of the patient be so en- 
feebled that we are neither able to limit nor to guide the inflam- 
matory process to a successful issue. 

470. Etiology. — Pelvic peritonitis probably never occurs 
as a primary disease, but always as a complication of a pre- 
existing disorder. Occasionally, however, it is the first recog- 
nized expression of such disease. The symptoms of peritonitis 
are so severe that attention is at once aroused, while the con- 
dition from which it originated may have been so insidious 
as to have been overlooked. From want of knowledge, then, 
of the previous condition we are often compelled to ignore the 
exciting condition, and to say that the patient suffers from 
pelvic peritonitis. Is it surprising that the original condition 
was formerly unrecognized and the disease denominated idio- 
pathic peritonitis, the result of a slight injury or of exposure 
to cold? It is true there are still cases in which we are un- 
able to discover the preexisting disease, but the number of 
such cases has become less and less frequent, and failure to 
determine the cause of pelvic peritonitis is the result of de- 
fective observation and of want of knowledge. 



INFLAMMATIONS. 441 

The most frequent cause is sepsis ; next, gonorrheal infection. 
The micro-organisms principally concerned in the develop- 
ment of infection are the streptococcus, the staphylococcus, 
the gonococcus, the bacillus coli communis, and the bacillus 
tuberculosis. The propagation of these infectious micro-organ- 
isms is favored by parturition, abortion, instrumental ex- 
amination, and surgical interference. Other causes are in- 
flammations of the appendix, intestinal perforations, abdominal 
lesions, rupture of an ectopic gestation, hematocele, ovarian 
abscess or hematoma, and malignant disease. 

Infection generally reaches the peritoneum in one of three 
ways: first, by the continuous mucous membrane through 
the uterine cavity and tubes; second, by the blood-vessels; 
third, by the lymphatics. 

Tubal disease is the most common cause of pelvic peri- 
tonitis, and should receive first consideration. The mucous 
membrane of the Fallopian tube is continuous with that of 
the uterus, and at its abdominal end opens into the peritoneal 
cavity. 

The continuity of the tubal mucous membrane with that of 
the uterus and vagina subjects it to continual danger of in- 
fection. The tendency of every acute infective endometritis, 
whether septic, gonorrheal, or tubercular, is to extend to and 
involve the tube. The relation of the tubal mucous mem- 
brane to the peritoneum, in infection of the former, favors 
its extension to the latter. This risk is further aggravated 
by the anatomic position of the tube in woman. No other 
mucous membrane is similarly situated. The uterine cavity, 
when inflamed, naturally drains into the vagina through the 
external os; but the tube has its most constricted portion 
toward the uterus, where the lumen of the canal is but large 
enough to permit the passage of a bristle. A very slight amount 
of swelling will be sufficient to close the uterine end, when 
the only outlet of the tube is into the peritoneum. The ab- 
sence of a suitable outlet for morbid secretions of the tube 
and the continuity of its mucous membrane with the perito- 
neum render inflammatory affections of the canal of especial 
importance and make pelvic peritonitis so frequent a conse- 
quence of salpingitis. 

A prompt result of peritonitis from tubal infection is closure 
of the abdominal ostium of the tube by adhesions or by in- 
flammatory changes in the fimbriae. The tube then becomes 
filled with retained secretion, and is the center for an inflamma- 
tory process which extends through the w^all to the neighboring 
tissues, especially the peritoneum. If this extension is not an 
immediate occurrence, the tube is subject to frequently recurring 



442 GYNECOLOGY. 

inflammatory attacks from slight causes. When the retained 
secretion consists of pus, the liability to recurring attacks of 
pelvic peritonitis is much greater than when the accumulation is 
serous or mucopurulent, to which liability is added the danger "of 
ulceration and thinning of the tube-Avall and the possibility of pus 
escaping into the peritoneal cavity by perforation or rupture. 
Frequently the ovary becomes infected from the tube, suppurates, 
and affords a fresh source of danger. Both inflamed tube and 
ovary may act as further sources of peritonitis, but sometimes the 
tube, after infecting the ovary, recovers and is no longer a focus 
for infection. Infection of the ovary is very prone to occur when 
the latter has been the site of cystic disease or when a Graafian 
follicle has recently ruptured. The most frequent mode of in- 
fection is through a cyst -wall which has become adherent to a 
diseased tube. Sometimes the infection occurs through an ul- 
cerative process which permits the tubal contents to enter the 
cyst suddenly by perforation of the cyst -wall. Tubo-ovarian 
abscess is thus explained. Such an infection may produce an 
attack of peritonitis more violent than any preceding. 

A more alarming attack of peritonitis is engendered by the 
escape, through ulceration, of the contents of a suppurating 
tube or ovary into the peritoneal cavity. Fortunately, such an 
occurrence is rare. The thinned wall of such a collection is a 
menace which places nature upon her guard and stimulates 
her to form adhesive barriers which will limit the space into 
which the rupture occurs and favors the formation of an intra- 
peritoneal abscess. Such an abscess may rapidly enlarge, 
and, if the patient survives, may burst into one of the neighbor- 
ing viscera, into the peritoneal cavity, or externally, accord- 
ing to its situation. Suppuration of an ovarian cyst may be 
independent of infection through the tube; occasionally, it 
more than probably occurs from the proximity of an inflamed 
growth to the rectum or intestine. The cyst is more vulner- 
able to such infection when it has been exposed to injury or 
subjected to bruising, as in labqr. 

Peritonitis may be favored by twisting of the pedicle of 
an ovarian cyst. This accident can result in strangulation, 
intracystic hemorrhage, inflammation, or necrosis of the growth, 
according to the amount of strangulation. The accident is 
particularly prone to occur during parturition. 

The presence of puerperal sepsis should be regarded as de- 
manding careful investigation. New pelvic growths, by their 
mere presence, may engender peritonitis. This is common 
in ovarian tumor. The tumor varies greatly in the prob- 
ability of its producing peritonitis. Uterine fibromata may 
attain a large size without adhesions unless degenerative proc- 



INFLAMMATIONS. 443 

esses set in, while a papilloma of the ovary, or tube, dermoids, 
and malignant diseases are usually associated with extensive 
peritonitis. 

Severe septicemia may follow abortion, parturition, or sur- 
gical manipulations, and, instead of being confined to the uterine 
mucous membrane, can at once be carried by blood-vessels 
or lymphatics to the peritoneum, and generate a diffuse septic 
infection in the pelvis. Such a peritonitis may become localized 
in the pelvis or may rapidly prove fatal by its extension to 
the general peritoneum. 

Clinical experience has demonstrated that injury alone 
will cause peritonitis only when the hand or instrument in- 
flicting the injury is surgically unclean. The truth of this 
assertion is illustrated by the infrequency with which exten- 
sive operative manipulation within the peritoneal cavity is 
followed by inflammation, and by the frequent attacks of 
virulent and fatal peritonitis following slight injuries in efforts 
to produce abortion. It is, without question, a mere prob- 
lem of infection. The operator in the latter is usually ignorant 
or reckless. 

Complications during parturition may cause peritonitis. 
The shape and size of the normal pelvis is adapted to the pas- 
sage of the normally constructed child at full term, and is with- 
out extra accommodation. Any encroachment upon the pelvis 
by tumor, growth, or malformation affords an obstacle which 
renders passage through the canal possible only at the expense 
of injury or bruising, which may result in loss of vitality of 
tissue or gro^^^th, and thus render the structures more suscep- 
tible to the influence of pathogenic micro-organisms. 

Pelvic cellulitis, it has been said, is generally secondary, 
but still it may precede the peritonitis. This is particularly 
true of suppuration. 

Pelvic hematocele is a source of peritoneal inflammation. 
The irritation induced by the blood diffused into the perito- 
neal cavity causes exudation and adhesive peritonitis. The 
blood-serum may be roofed in beneath adherent omentum 
and coils of intestine, when the peritonitis limits effusion and 
promotes its subsequent absorption. 

Inflammation of the vermiform appendix, or appendicitis, 
is a not infrequent cause of pelvic peritonitis. Its normal 
situation is in the right inguinal region, just above the brim 
of the pelvis, but instances have occurred in which it was found 
lying within the pelvis. In right-sided inflammation of the 
pelvic peritoneum an inflamed appendix should always be 
regarded as a possible source of the infection. An abscess 
formation may follow, which Avill fill up Douglas' pouch. In 



444 GYNECOLOGY. 

many cases it is difficult to determine whether the appendix 
or the right tube is the original source of infection. 

471. Pathologic Anatomy. — Inflammation of the peritoneum 
may be serous, adhesive, or suppurative, and acute or chronic. 
As it most frequently originates from infection through the 
tubes, the tubes and ovaries are, therefore, implicated. It 
begins as a congestion or hyperemia of the serous surface, 
with cloudy swelling of the endothelium. The membrane, 
instead of being smooth and glistening, becomes dull, dry, 
clouded, and slightly roughened with plastic lymph, w^hich 
is poured out between its adjacent surfaces. The adhesions 
thus produced are its most characteristic feature. In recur- 
rent attacks we find additional adhesions. Serum exudation 
becomes encapsulated, is found in the meshes of the connective 
tissue, may fill the culdesac or pelvis, posterior to the uterus, 
or it may be encysted to one side. Such collections may simu- 
late a cyst. When the exudation thrown out is considerable, 
it may form a distinct coating, which may be peeled from the 
surface of the peritoneum. These lymph coagula are also 
found floating in the serum, and, as the fluid becomes absorbed, 
this coating stiffens the peritoneum, and, with the induration 
in the subjacent cellular tissue, causes the hardness wdiich is 
one of the striking characteristics of chronic pelvic peritonitis. 

These indications of inflammation are usually most strongly 
marked about the fimbriated ends of the Fallopian tube, and 
diminish as they pass from it. When the inflammation has 
originated from some other cause, such as an inflamed appen- 
dix, the alteration and adhesions are most dense at the seat 
of origin. Thus, a Fallopian tube, when it becomes inflamed 
and increases in weight, drops from its original position, so 
that it is found upon the floor of the lateral fossa of the pelvis, 
in the pouch of Douglas, or adherent by its flmbriated end 
to the ovary or to the side of the pelvis. Occasionally the 
two tubes meet, and the distal ends become adherent to each 
other behind the uterus. At other points the direction of the 
tube may differ in two sides of the body. One side is bent 
like a horseshoe, while the other terminates against the lateral 
wall of the pelvis, to which it is adherent by its abdominal 
end. If the uterus is lifted out of the pelvis by pregnancy, 
the tube may be found situated above the brim, close to the 
border of the psoas muscle. The ovary is generally found 
implicated in the mass of inflammation which has extended 
from the tube. When this inflammation has existed for some 
time, we generally find the ovary in a cystic state, and con- 
siderably enlarged. These changes result from the effect of 
the surrounding peritonitis. 



INFLAMMATIONS. 445 

In chronic cases the peritoneum, in places, is lifted up by 
circumscribed collections of serous fluid in its meshes. These 
swellings vary in size from a pea to a large orange. They 
possess no pathologic importance, but often increase the diffi- 
culty in arriving at an accurate diagnosis. A mass formed 
by an inflamed tube, ovary, and broad ligament not infre- 
quently is found adherent to the posterior pelvic wall and rectum. 
Sometimes a coil of intestine or a portion of omentum may 
intervene, when the parts are so entangled in an extensive 
mass of exudation as to cause great difficulty in outlining and 
determining their relations. The body of the uterus is envel- 
oped in a mass of adhesions or is completely free. Whe.n 
the lesion from which the peritonitis has originated is puru- 
lent, peritonitis is also apt to be purulent, and, instead of an 
accumulation of serum, pus or intrapelvic abscesses are found. 
Occasionally, suppurative peritonitis exists. The latter occurs 
only in cases of exceptional virulence, or from sudden bursting 
into the peritoneal cavity of a pus-collection which was situated 
in an ovary or tube. Intraperitoneal abscesses may be single 
or multiple. They generally originate by the rupture of a 
suppurating Fallopian tube or by the discharge through' its 
abdominal ostium of pus into Douglas' pouch or into a space 
bounded by adhesions. Both tubes may thus discharge into 
a common receptacle, which is most generally Douglas' pouch. 
A tense, fluctuating swelling is formed, easily felt through 
the depressed vaginal roof, which, by pressure against the 
intestine, causes more or less obstruction. Purulent inflam- 
mation of the tube leads early to closure of the abdominal 
ostium, when the pus is confined within the tube, and forms 
what is known as a pyosalpinx. An intraperitoneal abscess 
or general peritoneal infection may then be induced by in- 
fection through the tubal wall, or by the bursting of the pyo- 
salpinx from ulceration Avithin, or by the spread of infective 
processes to the ovary, causing it to suppurate. 

An intraperitoneal abscess walled in by adherent viscera 
may run an acute course or may be retained for a long time, 
causing few, if any, indications of its presence. One of two 
things is likely to occur, how^ever: either the abscess gradually 
dries up and disappears, or its walls undergo ulceration and 
its contents escape into the bowel — usually the rectum, sig- 
moid flexure, or colon — or into the vagina, the bladder, the 
general cavity of the peritoneum, or some part of the abdom- 
inal wall. The most frequent exit is through the intestine. 
The other routes are exceptional. Such abscesses differ very 
markedly from cellulitic abscesses, and will quickly disappear 
when they have once found an outlet. The latter discharge 



446 GYNECOLOGY. 

their contents imperfectly. A troublesome sinus remains for 
years, producing serious ill health. Among the secondary 
changes resulting when salpingitis is unilateral is an exten- 
sion of the peritonitis to the other side of the pelvis, involv- 
ing the healthy uterine appendages in a mass of adhesions 
which complicate the function of both tube and ovary. Such 
a condition may be followed by hydrosalpinx. 

Hydrosalpinx may result as a sequel of salpingitis, but 
is less frequent than pyosalpinx. 

Effusion of blood within the tube (hematosalpinx) often 
arises as a consequence of tubal gestation, but occasionally may 
be independent of the latter. 

472. Symptoms. — The first characteristic of acute pelvic 
peritonitis is pain in the lower part of the abdomen, which 
is sudden in its onset. For a few hours it is extremely severe, 
associated with fever, with increased rapidity of pulse, and 
often with vomiting. An early symptom is more or less intes- 
tinal distention, which may be general or localized. Follow- 
ing the acute pain, movement is attended with great suffering, 
because of the tender, inflamed parts, and the patient is gen- 
erally obliged to remain in bed for a length of time dependent 
upon the severity of the attack. Rigors are infrequent, unless the 
condition is part of a diftuse septic inflammation or the re- 
sult of intraperitoneal rupture of a pyosalpinx or a suppu- 
rating ovary. Constipation is usual. Pain precedes defecation 
and micturition, owing to the contiguity of the inflamed part 
to the rectum or bladder. Not infrequently the pain is greater 
at the completion of micturition. The patient generally assumes 
the recumbent posture, with the limbs flexed, and guards 
the abdomen against the pressure of clothing or contact with 
the hand. In subacute or chronic cases pain in the back 
and inability to undergo physical exertion are experienced. 
Menstruation is more profuse than normal, often painful. 
Very trifling causes will result in recurrence of the attacks. 
This is particularly true when the chronic pelvic perito- 
nitis is maintained by the presence of pelvic suppura- 
tion. Recurrence of pain and abdominal tenderness are more 
reliable indications of the presence of pus than is elevation 
of temperature. Not infrequently a large quantity of pus 
may be found in the pelvis of the patient who has either a 
normal or a subnormal temperature. Patients in whom ex- 
tensive suppuration exists are found emaciated and incapac- 
itated for work or exercise. In the worst cases the patient 
will be bedridden. The amount of suffering depends upon 
the nature and extent of the disease and upon the social posi- 
tion of the patient; in other words, upon the demands that 



INFLAMMATIONS. 447 

are made upon her activity. In an acute attack the abdominal 
muscles are kept rigid over the affected parts. This rigidity 
is due to muscular contraction, and is beyond the control of 
the patient. Occasionally, by abdominal palpation a definite 
swelling can be recognized. This is particularly true when 
the mass is situated above the brim of the pelvis, has attained 
a large size, or presents an encysted exudation of serum or 
pus in front of the uterus or against the pelvic wall. Occasion- 
ally the abdominal enlargement will be due to the presence 
of serous fluid. When depression of the vaginal roof occurs, 
it will not be lateral, but central, because the accumulation 
of effusion, serous or purulent, is in Douglas' pouch. Upon 
vaginal examination the parts may be very tender, with a 
sense of resistance, or the uterus is pushed forward. After 
subsidence of the acute symptoms a careful bimanual examina- 
tion, for which an anesthetic may be required, Avill often re- 
veal in the posterior fossa of the pelvis the presence of a fixed, 
irregular, tender swelling. This begins at the uterine cornu 
as a cylindric body, equal in thickness to a lead-pencil; it may 
be rolled between the fingers, but may suddenly become thicker 
a short distance externally; it curves itself, may completely 
reverse its direction, and- finally ends behind the cervix uteri 
in the pouch of Douglas. A Fallopian tube can be adherent 
to the ovary, which is embraced within the concavity of its 
curve, and surrounded on all sides by a thickened, adherent 
peritoneum. The uterus is not always displaced, but is often 
found retro verted or retrofiexed, and adherent in its abnormal 
position. Again, it may be pushed forward by a mass of effusion 
in Douglas' pouch. The shape and consistence of the swelling 
vary in different cases, as the tube may be soft, sausage-shaped, 
particularly when its abdominal ostium is occluded, or it may 
be distended mostly at the outer end, which gives it the shape 
of a retort. Occasionally it is irregular, distended from sac- 
culation, thrown into knuckles or prominences, bent upon 
itself with sausage -like convolutions produced by intervening 
constrictions. Its consistence depends upon the extent to 
which the walls of the tubes have become thickened and upon 
the induration of the surrounding peritoneum. 

473. Diagnosis. — Peritonitis may be confounded with hema- 
tocele and cellulitis. Pelvic hematocele is readily distinguished 
by its clinical history, slight febrile disturbance, history of 
a possible tubal gestation, severe pain attending the rupture 
of the latter, and the subsequent bloody discharge from the 
uterus. The distinguishing features between peritonitis and 
cellulitis are as follows: 



448 



GYNECOLOGY. 



Peritonitis. 

1. Inflammation is chiefly confined to 

the pelvic peritoneum. 

2. Inflammation is bilateral. 



Cellulitis. 

1. Inflammation principally affects 

the pelvic cellular tissue. 

2, Inflammation is unilateral. 



Differential Diagnosis. — 

Peritonitis. 

1. Its onset is sudden, with severe 

pain, 

2. Both legs are drawn up. 

3. A firm, flat effusion surrounds the 

uterus or a mesial bulging is pro- 
duced by serous effusion in 
Douglas' pouch; the vaginal por- 
tion of the cervix is of normal 
length. 

4. The inflammation does not extend 

along the round ligament and 
iliac fossa, but it may affect the 
entire peritoneum. 

5. The uterus is displaced forward or 

backward. 

6. Vomiting is frequent. 



Cellulitis. 

1. Its onset is insidious, pain not 

marked. 

2. One leg is drawn up. 

3. A firm effusion bulges usually into 

the fornix of the one side; the 
cervix is apparently shortened on 
the affected side. 



4. Exudation, or pus, spreads in 

definite directions, and is usually 
localized. 

5. The uterus is displaced to one 

side. 

6. Vomiting is infrequent. 



474. Prognosis. — The mortality of peritonitis is much higher 
than that of celluHtis. Even when the patient recovers, the 
after-effects are more troublesome, and not infrequently the 
sequels are sufficiently serious to entail a life of chronic in- 
validism. The disease from which the peritonitis originates 
remains after the subsidence of the acute attack, and con- 
stitutes a focus from which subsequent attacks are likely to 
result, either from changes in the diseased tissues or from ex- 
ternal agencies. Recurring attacks of peritonitis are much 
more likely to occur when associated with the presence of pus, 
either in the form of pyosalpinx, suppurating ovary, or intra- 
peritoneal abscess. The damage done to the uterus, ovaries, 
and Fallopian tubes, particularly to the latter, by the obstruc- 
tion of the abdominal ostium, necessarily causes sterility. If 
the gradual absorption of the morbid products permits the 
occurrence of conception, the continuation of pregnancy to 
full term may be rendered impossible by the inability of the 
organ, from extensive adhesions, to becom^e enlarged. It 
is not possible, however, to say that pregnancy can not 
occur, for experience has demonstrated that even after the 
most virulent peritonitis the parts may so recover themselves 
as to permit of a subsequent conception. The discreet prac- 
titioner will consequently hesitate positively to assert that 
the patient can not give birth to children. Another effect of 
pelvic peritonitis is interference with the normal action of the 
intestinal canal. 



INFLAMMATIONS. 



449 



The termination must depend upon the condition of the 
individual patient. 

475. Treatment. — The first and most important aim of treat- 
ment is prevention. The large majority of nonpuerperal cases 
of pelvic peritonitis originate from a preexisting gonorrheal 
salpingitis; consequently the treatment should consist in the 
arrest of the infection before it has extended beyond the reach 
of local application. Unfortunately, gonorrhea is very frequently 
regarded as an unimportant affection, although it probably 
destroys the health of a larger number of women than does the 
much more dreaded poison of syphilis. The earlier symptoms 
of the disease usually 
pass unregarded. They 
are attended with but 
little pain — often none, 
if the urethra is not in- 
volved — and the signifi- 
cance of the purulent 
discharge is not realized. 
Medical advice, conse- 
quently, is unsought 
until the infection has 
produced serious results 
or has inflicted life-long 
damage. Even when 
advice is obtained, the 
disease is seldom re- 
garded seriously, and 
vigorous treatment is 
not employed. A puru- 
lent vaginal discharge 
in a recently married 
woman should always 
be regarded with grave 
suspicion, and its 
treatment should be undertaken with a due sense of responsi- 
bility. 

The object of treatment should be to prevent the extension 
of disease to the tube and the development of septic salpingitis. 
Its occurrence means a focus for the continuous distribution of 
infection and a cause for frequently recurring attacks of peri- 
toneal inflammation. Such invasion, as would naturally be 
inferred, is a frequent consequence of gonorrhea, but its avoid- 
ance requires rigid adherence to the rules of aseptic surgery 
and midwifery in the management of abortion, parturition, 
and surgical manipulation. Care should be exercised in the 

29 




Fig. 323. — Induration from Peritonitis. 



450 ' ^ GYNECOLOGY. 

examination of patients, and particularly when such investigation 
is to be intra-uterine. 

When the patient has once been the victim of pelvic peri- 
tonitis, it is extremely important that all causes likely to pro- 
voke a relapse should be avoided. She should be careful in 
her dress, should not be exposed to cold or damp, especially 
during her menstrual period, and exhausting exercise or over- 
fatigue should be guarded against. Prolonged standing is 
as disastrous as excessive exercise. She should be advised 
to secure sufficient rest, and the state of her bowels should be 
carefully watched. Intestinal adhesions naturally increase the 
tendency to habitual constipation. The fecal accumulation 
favors the development and migration through the coats of 
the intestines of pathogenic micro-organisms, so the tendency 
to constipation should be overcome by suitable aperients, or 
by enemas of glycerin or of soap and water. The medical 
treatment is very similar to that employed in pelvic cellulitis, 
with the exception that opium and its derivatives may be neces- 




^SiSSii*^^ 



sary in some cases of peritonitis. Their administration, how- 
ever, should be regarded as an unavoidable evil, and only small 
doses should be given, and these discontinued as early as pos- 
sible. Constipation should be prevented by appropriate aperi- 
ents or enemas, or both. Accumulation of scybala is more 
harmful than active purgation. During an acute attack the 
patient should rest in bed, and the diet should be restricted 
to liquid or easily digested food at regular intervals. The 
pain should be relieved by the application of the ice-bag, or, 
if this is uncomfortable, by hot fomentations. Intestinal dis- 
tention is relieved by the use of enemas. The patient will 
probably be tormented by thirst and by the desire for ice or 
to drink effervescent waters. She will find much greater re- 
lief from frequent sipping of hot water. Ice should be avoided, 
as, when once employed, it increases the thirst, and the patient 
will be constantly demanding it, with the result, if granted, 
that the mouth and tongue will soon suffer from a severe attack 
of glossitis. If the enemas fail to give relief, an aperient 



INFLAMMATIONS. 451 

should be administered — doses of calomel, castor oil, or, what 
is more efficient, sulphate of magnesium. The last may be 
given in one- to two-dram doses, dissolved in syrup of ginger 
and cinnamon- water, every two or three hours until the bowels 
are freely evacuated; subsequently three or four times a day, 
as the condition may demand. The state of the pulse is a more 
correct guide to the condition of the patient than the temperature, 
and will indicate the need for stimulants. If the pulse shows 
signs of flagging, becomes thin, feeble, and intermittent, brandy 
or whisky should be given in regular doses, diluted with five or 
six times the quantity of water, its effect being carefully watched, 
the dose to be increased or diminished according to its influence. 
Stimulants should not be allow^ed to take the place of food. The 
indications of collapse — coldness of the extremities, sunken 
features, flagging pulse, subnormal temperature — should be 
further combated by the application of external heat and by the 
hypodermatic inj ection of strychnin and atropin or digit alin. The 
intensely depressing effect of intestinal distention should be kept 
in mind, and this condition should be relieved by the use of ene- 
mas or by the introduction of a soft -rubber rectal tube with the 
patient turned upon the side. Not infrequently, as suggested 
by Keith, an injection of quinin, gr. vj, whisky, foss, and water, 
fSij, repeated every hour until three doses have been given, 
stimulates the nerve-centers and increases peristalsis. The 
most effective enema is an ounce of powdered alum dissolved 
in a quart of hot water. This is best given with the patient 
lying either upon one side or upon her back, with the hips elevated. 
This enema promotes peristalsis, and, consequently, is of service 
in tympanites. Where peritonitis is established and the patient is 
ejecting a dark- green fluid from the stomach and is unable to re- 
tain even liquids, the stomach should be irrigated through the 
stomach-tube with a normal salt solution. This should be re- 
peated if the vomiting returns. No food, not even water, should 
be allowed to enter the stomach. Peristalsis should be quieted 
by injection of gr. J -J morphin hypodermatically, followed by gr. 
-^Q 1^2 of the same agent every three hours. The nutrition should 
be maintained by rectal feeding, administering normal salt solu- 
tion three ounces, bovinine one ounce, every three or four hours, 
and, where necessary, hypodermoclysis or intravenous injections 
normal solt solution may be employed. 

The occurrence of peritonitis should lead to a careful examina- 
tion of the pelvis, and any indication of tenseness in Douglas' 
pouch or about the cervix should be considered an indication 
for immediate vaginal incision to break up the tissue and per- 
mit the fluid to escape. The opening should be kept patulous 
by the introduction of a gauze drain. Such a course will not 



452 GYNECOLOGY. 

infrequently arrest or limit the progress of the inflammation. 
The mere removal of the tension affords great relief. If an 
intraperitoneal abscess exists, such interference not only affords 
relief, but may anticipate its bursting into the rectum and 
establishing a troublesome sinus. Unless such conditions can 
be determined, however, it is wiser to defer surgical inter- 
vention until the acute symptoms have subsided. If the 
attack is the first the patient has had, and the swelling is so 
slight as to indicate a possibility of a probable nonpurulent 
inflammation, operative interference should not be advised. 
If the patient has repeatedly had similar attacks, and swell- 
ing of such a size is found as to render it probable that in its 
midst there is an occluded, distended Fallopian tube or an 
enlarged, cystic ovary, operation should be urged. Such a 
mass, with the recurring attacks, almost positively indicates 
the presence of pus; and where pus is present, surgery is ab- 
solutely indicated. It is impossible, of course, to lay down 
positive rules: every case must be personally decided. A 
woman from the laboring-class can not afford to spend as 
much time in invalidism as a woman in better circumstances. 
When operation has been decided upon as necessary, the 
method of procedure still remains undetermined. Abdominal 
section being the older and more generally adopted procedure, 
it will be first described. (For the preparation of the patient 
see Section 187.) The patient is placed upon the operating 
table, preferably one by which the Trendelenburg posture 
can be secured, and an incision from 2^ to 3 inches long is made 
in the median line, beginning an inch above the symphysis pubis. 
The operator must remember the possibility of adhesions be- 
tween the intestines, the omentum, and the anterior abdominal 
parietes, and should proceed carefully as he approaches the 
peritoneal cavity. Generally the omentum is adherent to the 
mass in the pelvis, over the surface of the uterus, the tubes, 
or the ovaries. The first step is to separate these adhesions 
and to free the omentum and any coil of intestine which may 
be adherent. The omentum and intestines are drawn upward 
to expose the matted contents of the pelvis beneath them. When 
the patient is lying fiat, we have to be guided almost entirely 
by the sense of touch. In the Trendelenburg posture we are 
aided in our manipulations by sight. Following the fundus 
of the uterus as a guide, the operator endeavors, with the tips 
of the first two fingers, to enucleate the diseased uterine appen- 
dages from their adherent surroundings. The fundus of the 
uterus may be free or implicated in the adherent mass. In 
the latter case its identification may be exceedingly difficult, 
rendering it necessary for an assistant to pass one or two fingers 



INFLAMMATIONS. 453 

into the vagina to elevate the uterus by pressure against the 
cervix. The fundus is thus identified. The affected tube, 
on one side, is traced out from the uterine cornu and made 
to serve as a guide when searching for planes of cleavage. If 
it turns backward and becomes lost in the adherent mass, 
the safest way is to keep the fingers close to the posterior sur- 
face of the uterus, and to trace the adherent mass downward 
to Douglas' pouch. In breaking up the adhesions it is neces- 
sary to separate the mass from the walls of the bowel, includ- 
ing the anterior wall of the rectum. It is often advisable to 
have an assistant pass his forefinger into the rectum, partly 
to facilitate the separation by steadying the bowel, partly to 
ascertain where the bowel is and whether the manipulation is 
in dangerous proximity to it. The separation of these adhesions 
in Douglas' pouch is generally the most difficult part of the 
operation. Indeed, I know of no operation more difficult than 
to have to break up adhesions which have existed for a long 
time between knuckles of intestine and the fundus of the uterus 
or the ovaries and tubes. The separation is to be continued 
posteriorly from below upward. When the mass has been 
cleared from its posterior and inferior attachments to the uterus 
and to the uterine appendages of the opposite side, there still 
remain adhesions to the back of the broad ligament, which 
has become more or less folded over the diseased parts, and 
forms a deep, concave surface on its posterior aspect. This 
concave surface has to be unfolded in order to permit the mass 
to be brought into view and the broad ligament below it to be 
transfixed. This separation can be accomplished by working 
from below upward, and should be continued until the ovary 
and tube remain attached to the uterus and broad ligament 
by their anatomic connections only. The pedicle is then tied 
in the same manner as in the removal of the normal ovary and 
tube for the relief of myoma. The appendages on the opposite 
side are examined, and are removed or left, according to their 
condition. If merely adherent, the operator may content 
himself by simply separating the adhesions. 

During such manipulation it is not infrequent to find an 
escape of pus, which may be independent of any fault of the 
operator. It is often difficult to accomplish without rupture 
the separation of adhesions around the ostium of a suppurating 
tube or the enucleation of a suppurating and adherent ovary 
the wall of which is thinned and nearly ready to burst. For- 
tunately, unless the pus is unusually virulent, no serious harm 
results. However, we should always exercise care, in such 
cases, to wall off the general peritoneum and intestine with 
several layers of gauze pads, to prevent their being soiled. 



454 



GYNECOLOGY. 



(Fig. 325.) Occasionally, in severe cases, when the patient 
is much depressed, the persistence required for the separation 
of extensive adhesions would so prolong the operation as to 
endanger the life of the patient. It may be necessary then to 
content ourselves with mere emptying and draining of the 
suppurating cavity. The greater the experience of the operator, 
however, the less frequent will be the incomplete operation. 
Separation of adhesions between different parts of the intestinal 
canal other than the rectum should be made as much as possible 
under the eye, and any injuries to these structures should be 




Fig. 325. — Intestines Held Back by Gauze. Patient in Trendelenburg Posture. 



immediately repaired. The inexperienced operator should be 
careful not to mistake a thickened and adherent intestine for 
an inflamed Fallopian tube. This mistake may be avoided by 
following the tube toward the uterus before an effort is made 
toward its separation. 

During the performance of these operations the general 
peritoneum should be carefully protected by drawing back the 
intestines and omentum, and retaining them with gauze or gauze 
sponges, so that they shall not be soiled by rupture of an abscess 
cavity. When the operator and his assistants have been unable 



INFLAMMATIONS. ■ 455 

to protect the intestines from the contact with the contents of 
the abscess, I think it better to irrigate the abdomen with hot 
normal solution, 105° to 112° F., and thus complete the peritoneal 
toilet rather than to attempt to accomplish it by dry sponging. 
In such cases the belly cavity may be left filled with the salt 
solution. Drainage must be decided by the indications of the 
individual case. The larger the experience of the operator, un- 
less he is particularly prejudiced, the less frequently will he be 
likely to use drainage. Even in the most virulent cases, with ex- 
tensive adhesions, irrigation of the cavity with a large quantity 
of normal salt solution, repeating it before the cavity is closed 
and leaving a considerable quantity of fluid within the abdomen, 
dilutes any poison that may remain and renders it less active and 
less likely to produce deleterious effects. In this way drainage 
may be avoided. In suppurative peritonitis McCosh suggests 
intra -intestinal injections of saline cathartic. He cleanses the 
peritoneal cavity thoroughly with irrigation instead of sponging. 
Through a hollow needle between one and two ounces of a 
saturated solution of magnesium sulphate is introduced into 
the small intestine at a point as high as possible in the jejunum 
or ileum. The needle-puncture is closed by a Lembert suture. 
The action of the saline produces free watery discharges, and 
thus makes the intestine act as a drainage-tube for the peri- 
toneal cavity. When drainage is used in suppurative cases, 
the gauze or wick drain, in which a number of strands are in- 
troduced into different parts of the abdominal cavity, is the 
preferable method of drainage. If the ends are carried well 
around the side of the body and are surrounded by cotton and 
gauze at a point below the level of the internal ends, we then 
secure a siphon-like action, which more effectually drains the 
cavity. 

Postural drainage was suggested by Clark, who thus utilized 
the healthy and unirritated portion of the peritoneum for ab- 
sorption. He recognized that, in the ordinary positions of the 
body, fluids, serum, and blood were likely to accumulate on those 
portions of the peritoneum which have been injured and con- 
sequently was less able to take care of them, and in which there 
were possibly still remaining tissues impregnated with pathogenic 
germs and the culture fluid was thus maintained in contact with 
the germs at a most favorable temperature. Such a misfortune 
can be avoided by elevating the foot of the bed thirty-six inches. 
The patient could be occasionally turned from one side to the 
other, so that no fluid would accumulate in the pelvis, but be 
thrown upward upon the healthy peritoneum, which was better 
able to take care of it. Other advantages for this posture were 
that a decreased amount of blood was sent to the injured part. 



456 GYNECOLOGY. 

lessening the amount of pain from which the patient suffered 
subsequent to the operation ; that it permitted immediate closure 
of the wound and greatly decreased the danger of a weak ventrum 
and a consequent hernia. The procedure suggested by Fowler, 
to elevate the body of the patient so that the drainage may ac- 
cumulate in the most dependent portion of the abdomen, 
whence it can be siphoned by a gauze wick emerging from the 
lower angle of the wound or into the vagina, has appealed to the 
profession as the more satisfactory procedure. In closure of the 
wound we must endeavor to utilize measures that will bring to- 
gether and hold in apposition the tissues, so that firm union may 
be secured and the risk of hernia lessened. Various methods of 
procedure have been employed to accomplish the purpose — ^the in- 
troduction of a double row of sutures or of a series of sutures, one 
in the peritoneum, another in the aponeurosis, and another in the 
skin. The difficulty in the introduction of rows of sutures, how- 
ever, is that not infrequently there are left dead spaces, in which 




Fig. 326. — Three-pronged Vulsellum. 

an accumulation of fluid occurs. This later becomes infected 
and results in the formation of an abscess, which necessarily 
weakens the wall. I endeavored to obviate this difficulty by 
the employment of the figure-of-8 suture. The suture was 
made to cross just in front of the aponeurosis or that portion of 
the abdominal wall which it is most important should be main- 
tained in apposition. The figure-of-8 suture was designed to 
accomplish the same purpose as a double row of sutures, but 
affording the advantage that the suture could be removed. It 
was found to have the disadvantage, however, that in order to 
secure apposition of the tissues, the suture was likely to be drawn 
so firmly as to result in a slough, which produced a stitch abscess. 
I have experienced the greatest satisfaction by a com- 
bination of continuous chromic catgut suture with interrupted 
silkworm-gut sutures. Beginning at either angle of the wound, 
the catgut suture is introduced external to the aponeurosis upon 
one side of the wound, brought out in the peritoneum and fascia 
of the opposite side, and then through the edges of the peritoneal 
wound until the other angle of the wound has been reached, 



INFLAMMATIONS. 



457 



when it is brought out above the aponeurosis. The silkworm- 
gut sutures are now introduced, including all the tissues above 
the peritoneum, the wound is cleansed, and the catgut suture 
continued, uniting the edges of the aponeurosis, when the 
wound is carefully dried before the introduction of the last 
turn and the tying of the knot. Again drying the wound, the 
silkworm-gut sutures are tied. This procedure gives secure 




Fig. 327. — Vaginal Incision for Pus-collection in the Broad Ligament. 



union of the peritoneum, aponeurosis, and skin with but one 
buried knot. When twenty-day catgut is used, the wound 
should be firmly secured against subsequent weakness. 

The silkworm-gut sutures serve as supports to the wound, 
and should be tied only closely enough to hold the surfaces 
in apposition. The after-treatment is similar to that of other 
abdominal operations. (Section 206.) The combined crescent 



458 



GYNECOLOGY. 



and vertical incision (see Fig. 79), where large masses do not have 
to be removed, has given me great satisfaction and greatly lessens 
the danger of hernia, while it affords an opportunity to conceal an 
unsightly scar beneath the pubic hair. 

Vaginal Section and Uterine Castration. — Many clinical 
observers have appreciated that the infected uterus, from 
which the disease had been transmitted to the peritoneum 




Fig. 328. — Incision through Vagina with Thermocautery in Vaginal Excision 

of the Uterus. 



and appendages, has continued to be a cause for discomfort 
and ill health after the secondary foci of infection — the ap- 
pendages — have been removed. 

Pean, in 1886, to insure relief in such cases, advocated 
the removal of the uterus through the vagina as a routine pro- 
cedure in all cases in which that organ had been involved in 
an infectious process. This operation he designated as uterine 



INFLAMMATIONS. 



459 



castration. The procedure was subsequently popularized by 
the advocacy of Segond and Jacobs. The diseased appendages 
may or may not accompany the uterus in its removal. In 
preparing for this operation the following instruments should 
be sterilized: Three double tenacula; four vaginal retractors; 
a knife; one pair of straight scissors and one pair curved on 
the fiat; four large and twelve small pressure forceps; an 
angiotribe; Deschamps ligature-carrier; needle-holder; needles, 
threaded with silk loops; chromic catgut, sizes o and 2. The 




Fig. 329.— Clamp Forceps for Securing the Broad Ligament. 

operator may also have at hand the thermocautery and a large 
number of sterile gauze sponges. The steps of the operation 
are similar to those in the performance of the ordinary opera- 
tion of vaginal hysterectomy. The patient is prepared as directed 
in Section 182. She is placed in the lithotomy position, and 
the uterus is exposed by the vaginal retractors, one anterior, 
a second posterior, and one on each side. These retractors 
are held by two assistants. The cervix is seized by a vul- 




Fig. 330. — Deschamps Needle Ligature Carrier. 



sellum or double tenaculum, dragged down, and a circular 
incision made through the vaginal walls, which will be nearer 
the OS externum anteriorly than posteriorly. Behind, the 
incision extends for half an inch or more above the os, and, 
if required, additional room can be secured in the vagina by 
lateral incisions in the vaginal wall which extend for half an 
inch outward from the circular incision, and parallel with the 
broad ligament. The incision about the uterus is often made 



460 



GYNECOLOGY. 



with the thermocautery, which has the advantage that, in 
addition to decreased bleeding, the burn prevents the surfaces 
from immediate union and affords better opportunity for drain- 
age. After cutting through the vagina the tissues are pushed 
away from the cervix with the finger, the separation between 
the bladder and the cervix is accomplished by blunt dissection 
with the finger or some blunt instrument, or by successive 
snips of the scissors. The late Joseph Eastman inserted the 




Fig. 331. — Drawing Down the Fundus. 



scissors, closed, near to the cervix and then separated the blades, 
which facilitated the dissection. The dissection can be more 
rapidly accomplished posteriorly, as there is but little danger 
of injuring the rectum. The dissection is completed front 
and back by opening the peritoneal cavity when the uterus 
is held by the broad ligaments, through which pass the uterine 
and ovarian arteries. The tissues upon each side are divided 
with successive snips of the scissors, and the uterine artery 
is seized with forceps as soon as exposed, or immediately when 



INFLAMMATIONS. 



461 



cut. The fundus of the uterus can then be tilted forward 
through the anterior fornix of the vagina. This permits the 
cervix to be carried upward. With the fingers passed over 
the fundus of the uterus the ovary and tube are followed upon 
the tense surface of the broad ligament and dragged down, 
when a pair of clamp forceps can be placed upon the broad 
ligament to secure it. This is usually done first upon the left 
side, after which the 
broad ligament is cut 
between the uterus 
and the forceps. 
This permits more 
^ ready access to the 
right tube and 
ovary , as the 
fundus of the uter- 
us is turned out 
of the way. This 
tube and ovary are 
brought down in 
a similar manner, 
the broad ligament 
clamped external to 
them, and the mass 
cut away. We have 
now the bleeding 
vessels secured by 
the pressure for- 
ceps. If the condi- 
tion of the patient 
is such as to make 
an expeditious op- 
eration desirable, it 
may be completed 
by simply packing 
the vagina with 
gauze between these 
forceps, carrying the 
gauze well over the 
ends of the forceps in order that the intestine shall not impinge 
against them and become injured. The forceps and vulva 
are covered with a sterile dressing and the patient put to bed. 
The forceps should be allowed to remain for forty-eight hours, 
the gauze for four or five days. The clamp method, while 
expeditious, has the disadvantage, however, that the tissue 
enclosed in the grasp of the forceps undergoes necrosis and 




Fig. 332. — Application of the Clamp Forceps to the 
Lower Portion of the Broad Ligament. 



462 



GYNECOLOGY. 



causes a disagreeable odor for two or three weeks subsequent 
to the operation. This condition is a w^orry to the patient, 
nurse, and physician. There is ahvays a possibihty of the 
infection of the structures and of the peritoneal cavity, so that 
the majority of operators prefer to employ the ligature. The 
upper part of the broad ligament, that in the grasp of the upper 
clamp, may be crushed with the angiotribe and ligated with 
chromic catgut in the groove. The angiotribe, however, should 
not be employed if the tissue has undergone inflammation 




Fig. 333. — Ligation of the Broad Ligament in Vaginal Hysterectomy. 



and contains more or less exudate. The angiotribe crushes 
this tissue, indeed, almost bites it off, and, therefore, does not 
preclude the possibility of bleeding. Care must be employed 
in the use of the ligature to make sure that it is firmly' tied 
and that it does not slip. The uterine arteries, if they are 
in the grasp of the small forceps, may be ligated with catgut. 
These, if they have been picked up separately, do not require 
a large mass within the ligature. In the employment of liga- 



INFLAMMATIONS. 



463 



tures in the pelvis, the catgut should be preferred, although 
it has the disadvantage of being more likely to slip. The liga- 
ture here is very likely to become infected, consequently, if 
it is a silk ligature, it leads to a profuse discharge, to the for- 
mation of extensive granulations, and to a condition which is 
uncomfortable to the patient and a source of worry to the 
physician. Therefore, the chromic catgut should be employed 
in preference to the silk, which is almost certain to become 
infected. The ideal 
method of operating 
is that in which the 
electrothermic angio- 
tribe is employed, as 
devised by Dr. A. J. 
Downes. This cooks 
the tissues to such a 
degree that hem.or- 
rhage is effectually 
controlled, and hence 
no ligature remains 
to act as a source of 
irritation. When the 
inflammatory exu- 
date in the pelvis 
has been extensive 
and has gone on to 
suppuration, so that 
we have pus- sacs in 
the broad ligament 
or in Douglas' 
pouch, the preferable 
plan of procedure is 
that the incision 
should be made 
through the poste- 
rior culdesac, the pus 
sacs opened, evacu- Fig. 334. 
ated, and irrigated 
before the general 

peritoneal cavity has been opened and disturbed. Gauze may be 
packed into the pelvis temporarily during the remaining steps 
of the operation. In some cases the uterus is so bound dowm 
by inflammatory exudate that the dissection through the ante- 
rior fornix of the vagina is somewhat difficult. In these cases 
the operation may be expedited by splitting through the an- 
terior lip of the uterus, holding each side of the organ with 




-Upper Portion of the Broad Ligament 
Secured by Clamp Forceps. 



464 



GYNECOLOGY. 



the double tenaculum, and drawing it down while the cervix 
is being split. This affords a better opportunity to observe 
the relation of the bladder and the uterus, and to keep within 
the layer of connective tissue in the septum. Splitting the 
cervix and making traction upon its sides enable us to see the 
relation of the bladder and, consequently, to avoid injuring 
it. Another modification is the amputation of the cervix 
after the lower part of the broad ligament has been cut through. 
This permits the more ready rotation dowmvard of the fundus 
through the anterior fornix, as it has a shorter arc through 
which to rotate. The fundus of the uterus may be rotated 
through the posterior fornix, but the anterior is preferable, 




Fig. 335.— The Introduction of Gauze after Removal of the Uterus. 



for the reason that it puts the broad ligament more readily 
upon the stretch and enables us the better to find the lines^'of 
cleavage between the tube and ovary and the other adherent 
viscera. If the ovary and tube are not readily brought down, 
or if the patient is suffering from chronic hyperplasia of the 
tubal and ovarian structures, by which these organs are often 
largely obliterated, we may apply the clamp on either side of 
the uterus prior to its removal. After the removal of the 
uterus we can then proceed in our effort to remove the ap- 
pendages upon each side; but should we fail in this or if the 
adhesions are very firm, these structures may be permitted 
to remain, taking care, of course, that all pus-pockets have 



INFLAMMATIONS. 



465 



been thoroughly broken up and packed with iodoform gauze. 
The great majority of these cases have been infected. It is 
certainly preferable to keep the wound open by packing it 
with iodoform gauze rather than to close the vagina and peri- 
toneal surfaces. Landau advocates and practises the bifur- 
cation of the uterus through the anteroposterior line as a pre- 
liminary. One half of the organ is pushed upward, the other 
is drawn down. This procedure affords much more room for 




Fig. 336. — Closure of the Vaginal Wound by Sutures. 



the manipulation necessary in the application of forceps, the 
use of the ligature, or in crushing with the angiotribe. It 
affords better opportunity, also, for dealing with the infected 
tube and ovary. As a preliminary, the peritoneum can be 
protected by packing with sterile gauze before we proceed to 
enucleate or separate the ovary and tube. In the employment 
of pieces of gauze it is very important, however, that the end 
30 



466 



GYNECOLOGY. 



of the gauze should be fixed with a pair of hemostatic forceps, 
as the gauze is very readily worked upward into the peritoneal 
cavity by intestinal peristalsis, and may readily get beyond the 
reach of the surgeon. Nothing is more annoying than to ex- 
peditiously perform an operation and subsequently have to 




Fig. 337. — Landau's Method of Delivering the Uterus after Its Complete Median 

Section. 



lose valuable time in hunting sponges. The nurse who dis- 
penses the sponges should do nothing else, and should keep 
an accurate account of the number of sponges she has given 
out. These should be accounted for before the operation is 
considered completed. 



DISPLACEMENTS OF THE PELVIC ORGANS. 

476. Changed Relations of Structures of Vulva. — The re- 
lations of the structures of the vulva are modified and dis- 
torted by hypertrophy, by varicose veins, by inflammatory 
exudates and deposits, by edema, and by hernia and tumors, 
but they are, however, so intimately connected with the deeper 



DISPLACEMENTS OF THE PELVIC ORGANS. 



467 



structures that they are not subject to anything like displace- 
ment. All the other pelvic structures ^ are capable of more 
or less marked displacement; still all are so closely relg^ted to 
and dependent upon uterine deviations that we will proceed 
to the consideration of the uterus and its displacement as a 
primary subject. 

477. Physiologic ^Movements of the Uterus and the Forces 
by Which It Is Sustained. — The uterus is a freely movable 
organ. It is suspended in the pelvis, with its fundus at or a 
little above the level of the brim of the pelvis, by the action 




Fig. 338. — Uterus Displaced by Distended Bladder. 



of the uterosacral, the uterovesical, and the inferior portion 
of the broad ligaments, and occupies the axis of the pelvis, 
with its cervix directed toward the last sacral vertebra. The 
supports of the uterus are not ligaments in the ordinary sense, 
but consist of connective tissue, into and through which run 
prolongations from the uterine muscular structure, so that 
the organ is virtually sustained by muscular action. That 
the uterus is supported by muscular action is evident from 
the fact that the organ moves upward and downward with 
every respiratory excursion, changes its position with that of 
the body, and is influenced by the distention and condition 



468 



GYNECOLOGY. 



of the surrounding viscera. In the normal position the uterus 
rests forward upon t^e bladder, in a position of slight ante- 
flexion, while the cervix is directed almost at a right angle 
to the axis of the vagina. Such a position is markedly changed 
by the distention of the bladder, which raises the fundus and 
decreases the angle between the uterus and the vagina until 
it becomes exceedingly obtuse (Fig. 338),, and in marked dis- 
tention, indeed, the uterine axis becomes nearly parallel with 
that of the vagina. The cervix is pushed forward by disten- 
tion of the rectum. (Fig. 339.) When the rectum and the 
bladder are both distended, the organ is elevated, and no longer 




Fig. 339. — Uterus Displaced by Impacted Rectum. 



finds room between these two viscera. It will be seen that 
the muscles, arranged as just mentioned, support the cervix. 
The movements of the body of the organ are influenced by 
the broad ligaments on each side, which prevent it from un- 
dergoing lateral change of position, and by the round ligaments, 
which act as stays to prevent it from falling backward, or to draw 
it forward, when the bladder is emptied. The round hgaments 
are, of course, an insignificant force, but it must be remem- 
bered that the uterus weighs less than an ounce, and we can 
understand, therefore, how they serve to maintain the uterus 
far enough forward to permit the intra-abdominal pressure 



DISPLACEMENTS OF THE PELVIC ORGANS. 



469 



to be directed against its posterior surface. So long as the 
intra-abdominal pressure continues upon the posterior surface 
of the uterus, it is held forward against the bladder. It is 
also important for the maintenance of the uterus in its normal 
place that the muscular structure of the pelvic floor shall re- 
main in normal condition. Relaxation of the vaginal walls 
and of the muscular structure, occasioned by injury to the 
pelvic floor in which the perineal muscles are torn through, — 
and, particularly, the levator ani, — withdraws a support, which 
sooner or later favors displacement. The normal condition 
of the peritoneum is a factor. This structure is certain to be 




Fig. 340. — Scheme of Dislocated Uteri. — (Dudley.) 



affected by loss of muscular tone and of muscular support. It 
is not one factor, then, but several, which combine to maintain 
the uterus in its normal relations. 

478. Pathologic Changes and What Constitute Them. — 

From what has been said of the physiologic changes of position 
in the situation of the uterus it can readily be perceived how 
difficult it is to draw the line of demarcation between physi- 
ologic and pathologic changes. It may be said that when the 
uterus undergoes such changes in its structure or in its envelopes 
that it becomes stable in a position which is at times regarded 



470 



GYNECOLOGY. 



as physiologic, it becomes pathologic and is known as displace- 
ment. Thus, the uterus may be pushed forward by a distended 
bladder, which will increase the angle between its axis and that 
of the latter ; but if it does not follow the bladder forward when 
that organ is emptied, the position becomes abnormal. 

These changes may result from : 

I. Neglect of hygiene on the part of an individual, either 
in permitting the bladder to become habitually overdistended 
or the rectum to be loaded with fecal matter until the uterus 
is so driven back that the intra-abdominal pressure is no longer 
directed upon its posterior, but falls upon its fundus or an- 




Fig. 341. — Uterus Pushed up by Tumor in Douglas' Pouch. 



terior surface, which will lead to changes productive of an 
abnormal fixation. 

2. Inflammatory changes in the uterus, leading to increased 
weight of the organ, straightening of the body, loss of its normal 
curvature, and, by the w^eight, displacement of the organ for- 
ward, by which pressure is exerted against the fundus of the 
bladder; or, again, the increased weight produced by inflam- 
matory conditions causes relaxation of the pelvic ligaments 
and consequent displacement of the uterus downward and 
backward, while the body is bent upon the cervix. This bend- 
ing may take place forward, backward, or laterally. 

3. The presence of inflammatory material in the cellular 
tissue and in the structures surrounding the uterus causes 



DISPLACEMENTS OF THE PELVIC ORGANS, 



471 



its displacement by the volume of exudation, and subsequent 
displacement in the opposite direction takes place by the re- 
sulting inflammatory contraction. The uterus may be dis- 
placed as a whole, while its axis still remains parallel to what 
it was before, causing a change of location; or, again, it may 
be turned upon its axis forward, backward, or laterally; may 
be bent upon its own axis; may be depressed downward; and 
may undergo torsion. 

4. The presence of growths, either of uterine or external 
origin. 

479. Classification of Displacements. — As may readily be in- 




Fig. 342. — Uterovaginal Prolapse. 



ferred from what has been stated in the previous section, the 
uterus is capable of displacement upward, downward, back- 
ward, forward, and laterally, and of being twisted upon its 
axis. Upward displacement is known as ascent; downward, 
as descensus or prolapsus uteri. (Fig. 340.) The location 
of the uterus is subject to change: thus, when it is situated 
toward the back part of the pelvis, hugging closely the hollow 
of the sacrum, it is known as a retrolocation ; close to the sym- 
physis pubis, as an antelocation ; and toward one or the other 
side of the pelvis, as a dextro- or sinistro -location, according to 
the side on which it is situated. When the direction of the axis 



472. 



GYNECOLOGY. 



of the organ is changed, it is known as a version ; with the fundus 
well forward, it is an anteversion; the fundus turned back- 
ward, a retroversion; and toward either one or the other side, 
a dextro- or sinistro-version. The organ may be bent upon 
its axis, in which event the cervix and fundus approach each 
other. This bending may take place forward, backward, or 
laterally, giving rise to the terms anteflexion, retroflexion, 
and dextro- and sinistro-flexion. Finally, it may be twisted 
upon itself, producing a torsion. 

480. Ascent is the least frequent form of displacement. 
Those conditions which increase the weight of the organ, natu- 




Fig. 343- — Vagino-uterine Prolapsus. 



rally, by force of gravity, depress it. It is only when the organ 
has attained a size so great that it is no longer accommodated 
within the pelvis that ascent occurs. This is recognized as a 
physiologic ascent in pregnancy, and occurs after the fourth 
month, when the uterus becomes so large that it can no longer 
be retained within the pelvis, and rests upon the brim. A 
similar state develops when fibroid growths are situated in 
the organ and become large. (Fig. 341.) The uterus is drawn 
or pushed up by growths which may have developed in the 



DISPLACEMENTS OF THE PELVIC ORGANS. 



473 



pelvis and become adherent to it. As they increase in size and 
rise out of the pelvis, they drag or push the uterus up with 
them. Ovarian tumors, extra-uterine pregnancy, extensive pel- 
vic exudation, hematocele, and retro-uterine gro\-\i:hs may bring 
about an elevation of the uterus. 

481. Diagnosis. — The elevation of the uterus is readily de- 
termined by digital examination. The cervix is absent from 
its usual position in the vagina; frequently so elevated as to 
be with difficulty reached behind or even above the symphy- 
sis; often a growth or mass fills the pelvis, over which the 




Fig. 344. — Vagino-uterine Prolapsus with Hypertrophic Elongation of the 

Cervix. 



cervix can not be reached. Greater difficulty is sometimes 
experienced in determining the condition which has caused 
the displacement, and this is more important than the treat- 
ment, for the latter is entirely dependent upon the cause pro- 
ducing the displacement. 

482. Descent, or Prolapsus.^Descent or prolapsus of the 
uterus varies in degree. By this term is understood a down- 
ward displacement of the organ, which is generally associated 
with retroversion, so that retroversion is often considered 
as the first degree of prolapsus. The uterus is situated at a 



474 



GYNECOLOGY. 



lower level, with the os directed in the axis of the vagina. The 
second degree of prolapsus is w^hen a portion of the organ pro- 
trudes through the vulvar orifice, and the third degree when 
the entire uterus is outside of the vulva. This term includes 
a partial or complete prolapsus or inversion of the vagina. Pro- 
lapsus is also divided into complete and incomplete, according 
to the situation of the uterus. When the organ is .still situated 
within the vagina or only a portion protrudes from the vulva, 
it is known as incomplete prolapsus, but when the entire uterus 
is external to the vulva, it is called a complete prolapsus. The 
term procidentia is also applied to prolapsus, but only when the 
entire uterus is external. Prolapsus is further divided into three 




Fig- 345- — Uterus Detached, Showing Hypertrophic Elongation of the Cervix. 



varieties, according to the relation of the uterus to the vagina. 
Thus, it is called uterovaginal prolapsus (Fig. 342), when 
the prolapsus begins in the uterus, which is extruded through 
the vagina with only partial inversion of the latter; (2) vagino- 
uterine prolapsus, when the prolapsus begins in the vaginal walls 
and more or less extensive protrusion of the vagina precedes 
the prolapse of the uterus (Figs. 343 and 346). In such cases 
the prolapsus of the uterus may be incomplete, while the vagina 
is inverted, and a hypertrophic elongation of the cervix exists 
(Figs. 344 and 345). The third variety is pseudo-prolapsus. 



DISPLACEMENTS OF THE PELVIC ORGANS. 



475 



In this condition a large portion of the cervix projects into or 
through the vulva, while the fundus retains its normal position 
and the vaginal walls are unaffected (Figs. 347 and 348). In 
the latter case the hypertrophic elongation takes place in the 
vaginal portion of the cervix. 

483. Etiology. — The causes of prolapsus may be classified 
under three heads: first, decreased support; second, increased 
weight; third, increased intra-abdominal pressure. These con- 
ditions can exert their influence separately, but they usually act 
in conjunction. Decreased support is characteristic of individ- 
uals who have given birth 
to one or more children, 
and in whom the pelvic 
structures have been in- 
jured during the process 
of parturition. Lacera- 
tion of the perineum or 
removal of the support 
of the posterior segment 
of the pelvic floor per- 
mits a protrusion of the 
anterior wall of the 
vagina and the bladder 
during the distention of 
the latter organ. This 
protrusion of the ante- 
rior segment of the pelvic 
floor, because of the close 
attachment of the blad- 
der to the cervix, drags 
upon the latter, and, 
unless the uterus is fixed 
by firm ligaments or 
inflammatory adhesions, 
the entire organ is gradu- 
ally brought into the 
axis of the vagina, with 

its fundus thrown backward, and the intra-abdominal pres- 
sure will subsequently be directed upon it or its anterior 
surface. The decreased support to the posterior wall of the 
vagina permits protrusion of this segment with the recttun, and 
the cervix is drawn upon by both the anterior and posterior 
vaginal walls. Decreased support may exist in women who have 
not given birth to children, where, owing to want of normal 
muscular development, to ill health, or to too straight a sacrum, 
the support is lessened and the muscles of the pelvic floor are 




Fig. 346. 



-Vulvar Appearance 
uterine Prolapsus. 



of Vagino- 



476 



GYNECOLOGY. 



greatly relaxed. If, in such cases, intra-abdominal pressure is 
increased, extensive displacement results. Prolapsus may thus 
be produced in the unmarried. In marked relaxation and want 
of pelvic support, which have resulted from lesions of parturition, 
the tendenc}^ to prolapse is increased b}^ enlargement of the 
uterus or by failure to complete the process of involution. The 
uterus remains heavy, so that these two forces, decreased support 
and increased weight, acting in conjunction, lead to descent. It 
is true, we may have prolapsus when the uterus is small; thus, 
in cases in which, subsequent to the climacteric, the patient loses 




Fig. 347. — Pseudoprolapsus. Cervix Within the Vagina. 



flesh, the absorption of the fatty cushion decreases the amount 
of support, and, with enfeebled muscular action, permits a small 
uterus to be driven through the pelvis. This is a cause of pro- 
lapsus in the aged. Increased intra-abdominal pressure may 
arise from want of hygiene in clothing, where tight corsets and 
heavy skirts fastened about the waist afford insufhcient room in 
the abdomen for the viscera, which are driven downward into 
the pelvis. Neglect of the evacuation of the bowels and of the 
bladder increases the tendency to displacements. Prolapsus is 



DISPLACEMENTS OF THE PELVIC ORGANS. 



477 



favored by straining at stool, by lifting and carrying heavy 
weights. Not infrequently a patient will give a history of having 
lifted a weight or of violent straining, after which a protrusion 
was noticed at the vulvar orifice. In such cases the condition has 
existed for some time, and in the majority has been aggravated 
only at the time of the extra effort. The presence of growths 
within the abdominal cavity — fibroid tumors, ovarian cysts — 
which press upon the uterus may force it down. In relaxation 
of the pelvic floor it is not unusual to observe a prolapsus of the 
uterus, which has been produced by the increased intra-abdominal 
pressure incident to the presence of a new-growth. 




Fig. 348. — Pseudoprolapsus. Cervix Protruding from Vulva. 



484. Symptoms. — In the early stages of prolapsus of the 
uterus there are no symptoms characteristic of the condition. 
The patient complains of a sensation of weight, pressure, dis- 
comfort in the bladder, a feeling of burning in the rectum, and 
dragging sensation while walking or standing — all of which may 
be associated with other conditions. As the prolapsus pro- 
gresses, the patient will notice a protrusion from the vulvar 
orifice, which is increased by straining and lifting. As this pro- 
trusion increases, the close association of the bladder with the 
cervical wall causes the uterus to be dragged down. The bladder, 



478 



GYNECOLOGY. 



with exceedingly rare exceptions, accompanies the displacement. 
Occasionally, however, the peritoneal fold may be driven down 
between the bladder and the uterus, and a prolapsus thus occur 
without the bladder being associated with it. With the continu- 
ation of the prolapse the anterior wall becomes more and more 
everted, and, not infrequently, forms a considerable-sized tumor, 
which projects anteriorly, is increased by straining, and forms a 
tumor with a smooth, globular surface. This protrusion of the 

anterior wall of the vagina 
and bladder is known as a 
cystocele. (Fig. 349.) The 
posterior wall of the vagina 
may be likewise protruded, 
though less frequently than 
the anterior. In cases of 
inversion of the vagina the 
posterior wall is generally 
associated, although even 
then not to the same degree 
as the anterior. (Fig. 349.) 
The posterior protrusion is 
known as a rectocele. The 
uterus is separated from 
the rectum by a prolon- 
gation of the peritoneum 
which extends below the 
rectum on the posterior 
wall of the vagina. In the 
inversion of the posterior 
wall of the vagina to form 
a rectocele, the intestine 
may or may not be associ- 
ated with it. Occasionally, 
the want of support of the 
anterior rectal wall permits 
it to be pushed downward, 
and form a diverticulum 
considerably below the 
anus, which renders the evacuation of the bowel difficult, and 
at times impossible, unless it is pushed up with the hand, when 
the scybalous masses situated in the pouch can be extruded. 
In complete prolapsus of the vagina with the formation of 
an extensive cystocele a portion of the bladder is situated 
below the level of the internal orifice of the urethra, and as 
this protrusion extends, the bladder is incompletely evacuated, 
the retained urine with mucus in this reservoir undergoes 




Fig. 349. — Anterior and Posterior Colpocele. 



DISPLACEMENTS OF THE PELVIC ORGANS. 



479 



decomposition, forming an ammoniacal urine, which irritates 
the mucous membrane of the bladder and produces a cystitis. 
In this diverticulum, with a plug of mucus as a nucleus, a 
calculus of considerable size can form; indeed, one weighing 
an ounce has been found in such a sulcus. With the protru- 
sion the distress of the patient is greatly increased, because of 




Fig. 350. — Cystocele. 



the bladder irritation and the friction of the protruding tumor 
against the clothing and limbs of the patient. The urethra, 
instead of passing upward and backward as in the normal 
situation, passes backward and even downward. The pro- 
truded vagina in a complete prolapsus may form a large tumor 
extending half-way to the knees, in which tumor is situated a 



480 



GYNECOLOGY. 



portion of the bladder, the uterus, ovaries, tubes, and prolapsed 
intestines — an extensive hernia (Fig. 352). The mucous mem- 
brane of the vagina loses its moistened, reddish appearance, 
and instead becomes pale, thickened, and covered with flakes of 
epithelium, and resembles the appearance of the skin. Bathed 
with urine and fecal matter, irritated by the clothing and by 
friction against the limbs, and congested from the decubitus, 
ulceration is produced upon the external os and upon the sides 




Fig. 351. — Prolapsus with both Rectocele and Cystocele. 

of the tumor, which, at times, causes extensive loss of structure and 
adds greatly to the discomfort of the patient. In the early stage 
of the displacement the menses are increased, possibly irregular, 
and occur at shorter intervals. Leukorrheal discharge is present, 
often profuse, as a result of the congestion of the organ. As the 
prolapsus becomes still more extensive and approaches nearer 
to complete prolapsus, menstruation is likely to be decreased and 
the leukorrheal discharge disappears. The displacement does 



DISPLACEMENTS OF THE PELVIC ORGANS. 



481 



not necessarily interfere with conception, as pregnancy has often 
occurred with complete prolapsus; but in the later stages the 
patient is more likely to be sterile. 

485. Diagnosis. — The patient considers every protrusion 
from the vulva to be a prolapsus or falling of the womb. The 
diagnosis would seem self-evident, but it must be conceded 
that not every such protrusion is necessarily a prolapse of the 
uterus, and it is important to determine the degree, the form 
of prolapsus, and the structures involved. This knowl- 
edge is obtained by inspection, while the patient is directed 
to increase the displacement by straining and bearing down, 
and is further confirmed by touch. A protrusion from the 




Fig. 352. — Irreducible Prolapsus. The Tumor Contained Uterus and a Large 
Pyosalpinx. Ulceration of Cervix. « 



anterior part of the vulva, which, on separating the labia, is 
found to be continuous with the urethra and anterior wall, is a 
cystocele. It is the most frequent protrusion from the vulva, 
and may be accompanied in part or wholly by the uterus. 
Cystocele is recognized by the finger entering the vagina be- 
hind the protruding mass, which can generally be replaced 
with ease. The cervix, when accompanying it, will be situated 
at its posterior surface. A protrusion of the posterior wall 
of the vagina is recognized by its continuity with the peri- 
neum, and the finger enters the vagina in front of it. Con- 
siderable protrusion of the vaginal walls may occur without much, 
if any, displacement of the uterus. The degree of displace- 
31 



482 



GYNECOLOGY. 



ment of the anterior and posterior walls of the vagina is recog- 
nized by the introduction of the finger around the uterus. Thus, 
the cervix may protrude from the vulva without there being 
any shortening of the posterior, and but slight shortening of 
the anterior, wall of the vagina. With inversion, or com- 
plete prolapse of the vagina (Fig. 351), the summit of the pro- 
trusion is occupied by the cervix, which may appear as the 

normal-sized opening, or 
external os; or, when 
laceration of the cervix 
has occurred, the lips 
may be widely everted, 
and show an irritated 
cervical mucous mem- 
brane. When prolapsus 
is complete, the uterus is 
situated in the tumor, 
external to the vulva, 
generally in the position 
of retroversion or retro- 
flexion ; rarely it is ante- 
flexed. The uterovaginal 
form of prolapsus is de- 
termined from the vagino- 
uterine variety by the 
lessened involvement or 
association of the vagina 
with the protrusion. In 
the uterovaginal form 
(Fig. 353) the uterus 
is driven through the 
vagina, drags with it 
the upper part, and 
finally results in partial 
inversion of the canal. 
A¥hen the prolapsus is 
complete, the uterus is 
likely to be small and 
its cavity short. In the vagino-uterine variety the prolapse 
begins at the lower segment of the vagina by a rolling outward 
of the anterior and posterior walls. The thickened and everted 
vaginal walls drag upon the cervix, and lead to displacement 
of the uterus; or, where the fundus is fixed by the condition 
of its ligaments or by inflammatory disorders, the cervix is 
drawn out, and causes a very marked elongation of the uterus. 
This condition is determined by placing the fingers of one hand 




Fig. 353- 



-Prolapsus without Protrusion of 
Vaginal Walls. 



1 



DISPLACEMENTS OF THE PELVIC ORGANS. 483 

in front of, and those of the other hand behind, the protruding 
mass, when we determine the situation of the fundus of the 
uterus. (Fig. 354.) The protruding tumor can be grasped 
between the thumb and fingers of one hand, when the fingers 
will distinguish the uterus outside the vulva, or the cord-like 
cervix protruding into the vagina, when hypertrophic elon- 
gation of the cervix exists (Fig. 355). The situation of the 
fundus can still further be recognized by the introduction of 
the finger into the rectum. By dragging upon the cervix with 
a tenaculum while passing the finger into the rectum the at- 








y 



/ 



f/. 




K 



Fi&- 354- — Determination of the Position of the Uterus by Bimanual Palpation. 

tenuation of the neck is determined, and the situation of the 
fundus is recognized (Fig. 356). In pseudoprolapsus the fundus 
is but little displaced from its normal situation. There is a 
protruding mass from the vulvar orifice, and the introduction 
of the finger into the vagina shows that the vaginal walls are 
not displaced; this elongation has taken place in that portion 
of the cervix which is situated below the vaginal attachments. 
It generally results from enlargement and increased weight 
of the cervix. The anterior segment of the vagina is attached 
to the cervix at a lower level than the posterior. Occasionally, 



484r 



GYNECOLOGY. 



we find a protrusion of the anterior wall of the vagina, and 
at its posterior surface the cervix, while the introduction of 
the finger into the vagina shows that the posterior vaginal 
wall is not displaced. (Fig. 357.) In other words, the elonga- 
tion has occurred in that portion of the cervix situated be- 
tween the attachment of the anterior and the posterior vaginal 
walls. 

In considering the differential diagnosis we must concede 
the possibility of the protrusion having arisen from a cyst 
in the anterior wall of the vagina, a hernial protrusion through 
the posterior fornix, a fibroid polypus, and an inversion of the 
uterus, associated w4th inversion of the vagina. Cyst of the 




Fig. 355. — Recognition of Uterus with Thumb and Fingers of One Hand. 



vagina is recognized by bimanual palpation. A catheter or 
sound introduced into the bladder, and a finger into the vagina, 
will reveal an abnormal thickness of the anterior wall, and the 
character of the condition will be readily disclosed. The bi- 
manual examination can reveal a fibroid polypus protruding 
from the orifice of the cer\^ix by a more or less distinct pedicle. 
Traction upon the timior and the introduction of a finger into the 
rectum will disclose the position of the uterus. Displacement of 
the rectum is not generally associated with prolapsus of 
the vaginal walls, and, when so, is less intimately connected. 



DISPLACEMENTS OF THE PELVIC ORGANS. 485 

Inversion of the uterus is recognized by a protruding tumor, 
which does not present an external os, is more sensitive, under 
careful examination shows the orifices of the Fallopian tubes, 
and is a globular, well-shaped tumor, which can, still further, 
lead to an inversion of the vagina in which the relation of the 
cervix to the tumor and the vagina is readily determined. 

Enterocele, or hernia through the posterior fornix of the 
vagina, is a rare condition, although I have seen two such cases 
in which the hernia extended to the vulva. (Fig. 358.) The 




Fig. 356. — Diagnosis of Position of the Uterine Body by Rectal Touch. 

tumor is generally more elastic and is greatly distended. The 
absence of the uterus, in association with it, is 'recognized. 
On reduction of the hernia the opening into the posterior fornix, 
through which it had passed, is readily recognized. 

486. Prognosis. — The results of treatment must generally 
depend upon the stage of development, the existing compli- 
cations, and the manner of life the patient is required to live. 
The earlier the displacement comes under observation, the 
less radical will be the means required to maintain the organ 
in its replaced position. When both uterus and vagina are 



486 



GYNECOLOGY. 



prolapsed, changes have taken place which are beyond our 
skill to restore to the previous condition. While much can be 
done for the comfort of the patient in all cases, still in some, 
however, it may be necessary to sacrifice the uterus and part 
of the vagina. The irritation to which the vagina is subjected 
will sometimes lead to the development of an epithelioma. 
(Fig. 359.) Not infrequently we will find gravity sores and 
extensive ulcerations as a result of friction and the interference 
with the circulation. The restoration and maintenance of 
the pelvic organs in their proper place will depend upon the 




Fig. 357- — Hypertrophic Elongation of the Cervix. Anterior Vagina Everted, 
while Posterior Retains Its Normal Position. 



complications which may be associated with the displacements. 
The most frequent complication is the sequel of inflammatory 
changes, in which the displaced organs are more or less fixed 
by extensive exudation and adhesions. In procidentia the 
protruding sac or hernia, in addition to the uterus and part 
of the bladder, is likely to contain the ovaries and tubes, and 
even a large portion of the large and small intestines. In- 
flammatory changes in such a condition may lead to an ir- 
reducible hernia, which must necessarily add very much to 
the distress and discomfort of the patient. Such a patient 
can neither sit nor stand with comfort. In one patient (see 



DISPLACEMENTS OF THE PELVIC ORGANS. 



487 



Fig. 352) a large protruding sac contained the uterus, ovaries, 
and tubes, the latter having become infected, and resulted 
in the formation of a quite considerable-sized abscess. For- 
tunately, the condition was irreducible, for otherwise the re- 
duction of such a mass into the abdominal cavity might readily 
have resulted in rupture of the tube and general infection of 
the peritoneum. In one instance I was obliged to remove 
the uterus because of a partial necrosis of its structure. Or- 
dinarily, hysterectomy would not be the operation of election, 
as the removal of the uterus leaves an open space, which it is 
difficult thoroughly to close, and favors the subsequent develop- 
ment of a vaginal hernia, which is difficult to remedy. With 




Fig. 358. — Enterocele through the Posterior Vaginal Fornix. 



the retention of the uterus and its proper anchorage in the 
pelvis it serves as a plug and obstruction to the redevelopment 
of a hernia. It is self-evident that the patient who is enabled 
to live a luxurious life need not be subjected to the same treat- 
ment as the woman who must maintain herself, and, possibly, 
the members of her family, by laborious industry. The former, 
by rest and proper hygiene, may be able to prevent the develop- 
ment of the prolapsus, consequently an operative procedure 
may be delayed or mechanical means employed to overcome 
the condition, while the woman who must earn her living at the 
washtub or by continuous maintenance of the upright position 
will be required to subject herself to operative interference in 
order to prevent a more extensive displacement. 



488 



GYNECOLOGY. 



487. Treatment. — The treatment of prolapsus uteri must 
necessarily depend upon the extent of the displacement, the 
involvement of the vagina, the distention of the vaginal orifice, 
and the age and physical condition of the patient. The most 
important treatment is prophylaxis. This consists in the care- 
ful management of the woman during labor and the puerperium ; 
the early repair of lacerations of the cervix and perineum; 
the examination of the patient subsequent to her delivery 
to determine the condition and situation of the uterus. The 
advent of inflammatory conditions should be followed by 
judicious treatment, such as the employment of hot vaginal 
douches; cold applications over the abdomen; rest in bed; 
depletion of the uterus ; and, where endometritis exists, the use 
of the curet. A heavy uterus should be sustained by tampons 




Fig. 359. — Vagino-uterine Prolapse Complicated by Proliferating Epithelioma. 

or a pessary, until the process of involution has been com- 
pleted. The treatment of prolapsus may be divided into hy- 
gienic, mechanical, and operative. Hygienic treatment com- 
prises the wearing of proper clothing. A woman with a ten- 
dency to prolapsus of the uterus should not wear tight clothing. 
The increase of the intra-abdominal pressure necessarily ag- 
gravates the displacement; consequently, the clothing should 
be loose. Skirts should be suspended from the shoulders rather 
than from the waist; the bowels should be kept regular and 
all straining at stool avoided ; lifting and carrying heavy weights 
should not be undertaken ; the patient should frequently assume 
the knee-chest position, and, while in this attitude, separate 
the vulva in order that the air may enter and magnify the in- 
fluence of gravity in restoring the displaced organs. This 
position should be particularly assumed for several minutes 



DISPLACEMENTS OF THE PELVIC ORGANS. 489 

as a last act before retiring, and patients should assume the 
lateral or prone position rather than the recumbent. 

Mechanical treatment of prolapsus consists : (i) in the reduc- 
tion of the displaced uterus or its return to a normal position ; (2) 
in the employment of means to insure that this position will be 
maintained. The first step, then, in treatment is to replace the 
displaced organs. Ordinarily this is not difficult, as the increased 
size of the vaginal canal readily permits the organ to be carried 
upward to its proper place. AVhere the displacement, however, 
is complicated by inflammation with extensive exudation into 
the pelvis, it may result in matting together the uterus, ovaries, 
and tubes with knuckles of intestine and portions of omentum. 
Such a condition will render the restoration of the organs ex- 
ceedingly difficult, if not impossible, without resort to operative 
interference. Sometimes the displaced uterus, from passive 
congestion or edema, will become so large and engorged that 
it can not be replaced through the pelvic canal. This is par- 
ticularly prone to occur in those cases in which the prolapse 
is complete and the uterus and vagina have been subjected 
to friction against the clothing, causing the formation of gravity 
sores, and swelling to such an extent that the mass is rendered 
too large to be returned through the pelvis. Such a tumor 
may sometimes be reduced in size by the application of an 
elastic bandage, or by keeping the patient perfectly quiet in 
bed, with the pelvis somewhat elevated, and cold applications 
applied to the swollen structures. Cloths wet with lead-water 
and laudanum and covered with oiled silk, over which an ice- 
bag is applied, will frequently be effective in relieving the en- 
gorgement, and after a few days' treatment will result in such 
a decrease in size as to permit the parts to be reduced. The 
organ can be replaced with much greater ease by placing the 
patient in the genupectoral position. While the patient is 
in this position the tumor can be drawn down, compressed 
with the fingers, and gradually pushed up to its normal site 
within the pelvis. A mass too large to permit of its replace- 
ment with the patient in the dorsal position can generally 
be returned while in the knee-chest posture. When the uterus 
is fixed by inflammatory exudate, the patient should be put 
to bed, the parts subjected to pelvic massage, and in the in- 
tervals the uterus supported as high as possible by tampons 
of cotton and gauze, or, probably still better, lamb's wool 
saturated with medicinal agents, in which glycerin shall form 
an essential part. This treatment should be alternated with 
hot vaginal douches. Inflammatory adhesions may also be 
overcome by the employment of continuous weight or pressure. 
This is rather difficult to apply within the pelvis, because of 



490 



GYNECOLOGY. 



its being the most dependent portion of the trunk. The patient 
can be placed upon her side, with the pelvis somewhat elevated. 
Pressure is then obtained by introducing a small rubber bag, 
containing mercury, into the vagina. The continued pres- 
sure thus directed upon the surface will promote the absorp- 
tion of the exudation, and, by change of position, the uterus 
can be gradually worked free from the exudate. Thus, tampons, 





Fig. 360. — Ring Pessary. 



Fig. 361. — Disc Pessary. 



douches, massage, and pressure should be employed until 
the uterus becomes freely movable and its reposition is accom- 
plished. This, of course, is desirable as a preliminary to the 
employment of such a mechanical stipport as the pessary. 
In cases of prolapsus the pessary acts by so distending the 
upper part of the vagina that the levator ani and the muscles 
of the pelvic floor form a support for the instrument, and thus 
prevent the displacement. Consequently it is necessary that 





Fig. 362. — Smith-Hodge Pessary. 



Fig. 363. — Munde Pessary. 



the pessary shall be of sufficient size to accomplish this dis- 
tention. The pessaries most frequently employed are the 
ring (Fig. 360), the bulb, the disc (Fig. 361), the Smith-Hodge 
(Fig. 362), or Thomas or Munde (Fig. 363) modification of 
the latter. Numerous other pessaries are employed, such 
as the soft-rubber pessaries (Fig. 364), the Zwank or bat-like 
pessary (Fig. 365), the Gehrung (Fig. 366), the double curved 
pessary, the saddle or Graily Hewitt (Fig. 367), according 



DISPLACEMENTS OF THE PELVIC ORGANS. 



491 



to the purposes intended to be accomplished by their designers. 
In the employment of many of these pessaries, however, it is 
absolutely necessary that the pelvic floor shall afford a point 
of resistance to the intra-abdominal pressure. In cases in 
which the pelvic floor has been lost, or where the prolapsus 
is of the vagino-uterine variety, the pessary, having no point 
of resistance, is at once extruded when the patient makes a 





Fie. 



364. — Hoffman Soft-rubber 
Pessary. 



Fig. 365. — Zwank Pessary, 



straining effort, or even upon standing. In such cases a pessary 
may be employed with an external support. This is in the 
form of a cup with a stem attached to straps which are fastened 
to a belt around the waist. Such an instrument, however, 
is exceedingly uncomfortable ; the stem and straps are irritating 
to the delicate external surfaces. The cup may cause ulceration 
and abrasion of the cervix and vagina. The employment 





Fig. 366. — Gehrung Pessary. 



Fig. 367. — Hewitt Cradle Pessary. 



of a pessary in prolapsus can only be palliative ; it has no power 
to restore function to the part. However, a patient came 
under my observation who had worn a pessary for twenty- 
six years. This had produced such marked abrasion and 
irritation of the vagina that granulations had sprung up which 
enveloped the greater part of the instrument with new tissue. 
The pessary was cut with bone-pliers, and each half removed 



492 GYNECOLOGY. 

separately, leaving undisturbed the mass of cicatricial tissue 
by which the uterus was subsequently supported. I have 
seen, in several instances, the bulb or glass-ball pessary worn 
for a long period of time, until it resulted in cicatricial changes 
in the vagina, which formed the support for the atrophied uterus. 
The maintenance of the uterus by the establishment of cicatricial 
tissue has been attempted by the injection of quinin and other 
irritating materials into the broad ligaments. This was done 
in order to establish a cellular inflammation, which should 
cause such contraction of the connective tissue as to retain 
the uterus in position. Such a plan of treatment, however, 
is attended with too much danger to justify its employment. 

The operative treatment affords the only means which can 
be considered radical, or as giving hope for the restoration 
of the structures and their maintenance in normal position. 
In the employment of such measures I wish to direct your 
attention to the three causes which have been assigned for 
the development of prolapsus. These are, increased weight 
of the uterus, decreased pelvic support, and increased intra- 
abdominal pressure. The malposed uterus is rendered heavy 
by a condition of subinvolution or chronic inflammation, which 
has in part resulted from obstruction to its circulation. Not 
infrequently will we find that the cervix has undergone hyper- 
trophic elongation, and that the vaginal walls are dragging 
upon this elongated portion of the organ. The first step, then, 
in the restorative process, should be the amputation of the 
cervix. This decreases the size of the uterus, not only by the 
amount of the cervix removed, but by the favorable metabolism 
thus engendered. The amputation may be free or the double- 
flap or single-flap method can be employed (see Amputation 
of CeWix, § 336), according to the particular pathologic con- 
dition present. In performing this operation we would suggest 
that the cervix be sutured with chromic catgut, as such sutures 
can be allowed to remain; moreover, the stretching of the 
newly united surfaces consequent upon the removal of 
sutures is thus avoided. The second indication is met by 
narrowing the vaginal canal and reconstructing the pelvic 
floor. Early in the history of gynecology various operations 
were devised to secure this object. Sims did a triangular 
denudation upon the anterior wall, the surfaces of which were 
united and the canal thus reconstructed. The method of 
freshening the surface will largely depend upon the character 
and form of the prolapsus. The protrusion of the anterior 
wall of the vagina, for which these procedures are considered, 
is known as cystocele. Furthermore, the maintenance of the 
uterus in position by narrowing the vagina will be especially 



DISPLACEMENTS OF THE PELVIC ORGANS. 



493 



applicable to the correction of the cystocele. In cystocele we 
have to deal not only with the protrusion of the vaginal wall, 
but also with an accompanying prolapse of the bladder; a por- 
tion of the bladder is consequently oftentimes below the level 
of the internal orifice of the urethra. The portion thus dis- 
placed, as we have seen, affords an opportunity for ammoniacal 
fermentation and decomposition of the urine. In the sulcus 
or depression thus formed, not infrequently calculi are devel- 




Fig. 36S. — Anterior Colporrhaphy. iVnterior Vaginal Wall Removed. 



oped, which further aggravate and add to the distress of the 
patient. Any operative procedure, then, should comprise 
not only the contraction of the anterior vaginal wall, but the 
elevation of the bladder to a higher level. This change of 
the bladder position is accomplished by an incision through 
the anterior vaginal wall into the connective tissue between 
the vaginal and vesical surfaces. The edges of this incision 
are held with forceps, while, by blunt dissection or with sue- 



494 



GYNECOLOGY. 



cessive snips of the scissors, the vesical surface is dissected off; 
this dissection is extended upon either side to a degree sufficient 
to permit the removal of the relaxed tissue of the anterior 
vaginal wall. The bladder should then be pushed away from 
the cervix, up to or even through the peritoneum. (Fig. 368.) 
This dissection is followed by tucking the bladder up from 
below, and stitching it fast to the cervix at a higher level. This 
method renders the posterior surface of the bladder more tense. 

Some operators have 
advocated anchor- 
ing the bladder to 
the anterior parietes 
through an abdomi- 
nal incision, but such 
a procedure will be 
necessary in but few 
cases. The traction 
upon the bladder and 
its fixation to the 
anterior surface of the 
uterus will decrease 
the pressure against 
the reconstructed 
vaginal walls. The 
vaginal incision 
should be united from 
near the cervix, and 
the suturing extend 
outward, the cervix 
being pushed as we 
proceed. In this man- 
ner a strong anterior 
segment of the pelvic 
floor is established. 
(Fig. 369.) The su- 
turing should be done 
in a vertical line with 
a continuous chromic 
catgut suture, which should be locked at every second turn, 
in order to prevent puckering of the wound. The aim of 
the operator should be- to make a long anterior wall, to hold 
the cervix backward, and, consequently, tilt the fundus uteri 
forward. In greatly relaxed vaginal walls the excision may 
be made circular, and the wound closed with the Stolz's suture. 
(Fig. 370.) This, however, contracts the vagina in every 
direction and, therefore, is less favorable in the majority of 




Fig. 369. — Wound Closed. 



DISPLACEAIEXTS OF THE PELVIC ORGANS. 



495 



cases than the method of anterior colporrhaphy already de- 
scribed. The ordinary method of performing the operation, 
known as anterior colporrhaphy, consists in making a denuda- 
tion which does not penetrate the entire vaginal wall. When 
suttired, such a denudation forms a wall of connective tissue, 
which is not so durable as the method we have described. The 
operation upon the anterior vaginal wall should be supplemented 
by one upon the posterior. This may be slight or extensive, 




^ig- 370- — Stolz's Purse-string Suture. 



according to the amount of relaxation. The restoration of 
the posterior segment may be accomplished by performing 
the operation known as the modified Garrigues-Hegar, or the 
operation designed by Emmet. For a description of the method 
of performing these operations see Section 372. The decrease 
in the size of the uterus, the restoration of the pelvic floor, 
as described, will, in some cases, prove effective in maintain- 
ing the uterus in its proper position. In others, however, 



496 GYNECOLOGY. 

in which the uterus is large and does not maintain its proper 
axis, but drops backward, the intra-abdominal pressure will 
tend to drive it through the newly united canal and reestablish 
the hernia. It is consequently important that the uterus 
should be anchored within the abdomen, to prevent such an 
occurrence. This anchoring of the uterus may be accomplished 
by the operation known as ventrosuspension, or, still better, 
ventrofixation. For the description of this operation and 
its indications and contraindications see page 541. The same 
purpose can be effected by one of the operative procedures 
which utilize the round ligaments, as in the Alexander, the Gil- 
liam-Ferguson, the Ries, or other modifications, which will 
be described later. The aim, of course, of the operative pro- 
cedure is to maintain the fundus of the uterus forward. This 
can be accomplished by vagino-uterine fixation or by shortening 
the round ligaments through the vagina. These operations 
can readily be done in association with those upon the anterior 
wall of the vagina, as in the procedure we have already described. 
When the bladder is pushed away from the cervix, it is very 
easy to enter the peritoneal cavity through an anterior colpotomy 
and employ the opportunity thus afforded to break up adhesions, 
to treat ovarian and tubal disease, and to restore the uterus 
to its normal position. The incision through the posterior 
vaginal fornix is also employed for shortening the uterosacral 
ligaments. It will readily be understood that if the cervix 
is carried upward and backward, the fundus will necessarily 
fall forward. The contraction of the uterosacral ligaments, 
or the tissue in which they are usually situated, is of special 
value in marked prolapsus, for if the ventrosuspension or fixa- 
tion, or one of the operations upon the round ligaments alone, 
is done, we would have the uterus hanging and dragging upon 
its anchorage. Shortening the uterosacral ligaments, however, 
lifts up the cervix and, consequently, throws forward the fundus, 
thus making the uterus serve as a plug to obstruct the egress 
through the pelvis. Where the utero-sacral ligaments are short- 
ened as a part of the general procedure, they should be exposed 
before the sutures are tied in the operation upon the anterior 
vaginal wall. Bovee advises that the ligaments be exposed by 
a vertical incision from the posterior surface back toward the 
rectum, which shall extend to but not through the peritoneum. 
The latter is pushed off on either side until the thickening in- 
dicating the position of the ligament can be determined. Each 
ligament should be seized with a hemostat about its middle and 
drawn downward, while traction upon the cervix is discontinued. 
Each loop should be transfixed by a suture which is tied and the 
end of the doubled ligament secured just behind the cervix, near 



DISPLACEMENTS OF THE PELVIC ORGANS. 



497 



•' 



the normal attachment of the ligament. This course applied 
to both ligaments results in holding the cervix at a higher level 
and may in many cases obviate the necessity for opening the ab- 
domen. The sutures for closing the wound in anterior colpor- 
rhaphy should have been introduced and secured by hemostats 
before the incision to expose the uterosacral ligaments, and after 
the latter are secured, 
as we have indicated 
above, the former should 
be tied and by this 
course no traction is 
made upon sutures after 
they have been secured. 
These measures may 
be further supplemented 
by the retraction of the 
posterior vaginal wall or 
pelvic floor. When the 
ligaments have been se- 
cured, the vaginal inci- 
sion for their exposure 
should be united by con- 
tinuous catgut suture, 
leaving a vent through 
which gauze drainage 
can be employed. 
Freund advised in aged 
women, in whom the 
prolapsus was marked 
and the condition of 
the patient unfavorable 
for a radical operation, 
that silver wire sutures 
should be passed so as 
to form successive rings 
beneath the uterus. 
The introduction of the 
sutures should begin im- 
mediately beneath the 
cervix, so as to push up 
and maintain the organ at a higher level. He directed that they 
be drawn moderately tight and fixed by twisting ; the ends are then 
cut off and pushed into the vesicovaginal septum. The silver wire 
thus secured forms successive, bands or hoops around the restored 
vagina, which it was thought would maintain the uterus in place. 
My own experience, however, is that upon very slight exertion 

32 




Fig. 371. — First Stage of Dudley's Bilateral 
Denudation of the Vaginal Walls for Pro- 
lapsus. 



498 



GYNECOLOGY. 



the entire condition is reestablished. Moreover, the silver wire 
sutures are likely to cause irritation and possibly the formation 
of abscess, which will ultimately require their removal. Attempts 
have been made to maintain the uterus within the pelvis by in- 
flammatory changes in the broad ligaments. Injections of quinin 
hypodermatically have been employed for this purpose, but such 
procedures must be futile, inasmuch as they meet but a part of 
the required indications. Wiggins endeavored to accomplish 
the same by an intraperitoneal purse-string suture in each broad 
ligament. In prolapsus of large uteri, complicated by inflamma- 
tion of the tubes and 
ovaries, with bands of 
adhesion fixing omen- 
tum or coils of intes- 
tine to the uterus and 
bladder and with the 
subsequent cicatricial 
changes, the prefer- 
able plan of proced- 
ure, in my judgment, 
is the partial or com- 
plete removal of the 
organ. Even so radi- 
cal a procedure should 
be supplemented by 
a plastic operation 
upon the vagina, in 
order to narrow the 
canal and afford 
better support to the 
abdominal viscera. 
Such patients, even 
though old, bear op- 
eration fairly well. 
Where the condition 
of the uterus will permit of its retention, the organ should not be 
sacrificed. We have already cited reasons why hysterectomy 
should not be the operation of election. In hypertrophic elonga- 
tion of the cervix it may be difficult, by simple amputation of 
the cervix and fixation of the uterus, to sufficiently elongate the 
vagina to prevent recurrence of the hernia. In such cases, 
especially where the woman has passed the climacteric, the 
supravaginal amputation of the fundus uteri, through an abdom- 
inal incision, followed by suturing the stump, covered with peri- 
toneum, to the broad ligaments upon each side, as advocated 
by Baldy, will be effective, or, when the vagina is very much 




Fig. 372. — Dudley's Operation, Showing Denuda 
tion upon One Side of the Vagina. 



DISPLACEMENTS OF THE PELVIC ORGANS. 



499 



relaxed, we may sew the stump of the cervix directly to the 
abdominal parietes, as advocated by Noble. E. C. Dudley 
asserts that the part of the vagina most resistant to displace- 
ment is its lateral surface, and that, instead of narrowing the 
vagina on the anterior and posterior walls, the preferable plan 
of procedure would be to denude an elliptical surface upon either 
lateral fornix, with the long diameter anteroposterior. The edges 
of newly made surfaces are apposed and secured with sutures 
through the long diameter. From this a lateral denudation is 
made upon either side, in which the sutures are introduced from 
behind forward and from above downward, in such a way as 
to lift up the anterior wall of the vagina. (Figs. 371 and 372.) 
Even in marked cases of prolapsus sutures may be introduced so 
as to in some degree serve 
to anchor the lateral sur- 
faces of the vagina. 

.488. Urethrocele. — 
The urethra, in extensive 
cystocele, is generally 
more or less involved. 
As has already been rec- 
ognized, the intimate 
connection of the bladder 
and urethra with the 
anterior vaginal wall 
necessitated their associ- 
ation in any prolapsus 
of the latter structure. 
When a segment of the 
bladder is situated below 
the internal orifice of the 
urethra, the upper part 

of the urethra, as a consequence, becomes prolapsed. The lower 
segment of the urethra, however, generally retains its normal 
situation. Occasionally we may have a protrusion from the 
central portion of the urethra, which forms a sac-like projec- 
tion (Fig. 373) at the lower portion of the anterior wall of 
the vagina. This latter condition is independent of any uterine 
or vaginal displacement. This projection, on the introduc- 
tion of a catheter, is found to be a part of the urethra. It is 
at times so large as to form a kind of diverticulum, over which 
the urine flows, without entering it, or enters it only to a limited 
extent. Pressure over the urethrocele causes a discharge of 
quite profuse purulent material, although pus has not previously 
been found in the urine. The treatment consists in dissecting 
out the sac, a catheter having been previously introduced as a 




Fig. 373. — Urethrocele. 



500 GYNECOLOGY. 

guide. The opening in the urethra is closed while the catheter 
is in place. The vaginal wall is then sutured over this wound, 
and the urine is subsequently evacuated through a permanent 
catheter for two or three days. 

489. Dislocation of the uterus is a displacement in which 
there is but slight change in its axis. These dislocations may 
be forward, backward, or lateral. The organ is more or less 
fixed in the abnormal position by inflammatory changes, fre- 
quently in the form of inflammation of the cellular tissue. In 
p,nte position the uterus is situated close to the symphysis, gener- 
ally above it, and the condition is produced by growths or by 
accumulations in the pelvis which push up the uterus. The 
organ, once fixed in the abnormal position, remains. In retro- 
position the uterus is situated at a lower level, and close to the 
hollow of the sacrum. It results from inflammatory changes 
which contract and fix the organ; thus, a hematocele in its 
earlier stages may push the uterus forward into a state of 
anteposition, but later, as the collection becomes absorbed and 
organized, contractions occur which draw the organ back- 
ward. When the contraction involves the region of the folds 
of Douglas or the uterosacral ligaments, the fundus of the 
organ will be pushed forward, and an anteflexion will be es- 
tablished. It is only when the organ has previously been 
the seat of metritis and has become so rigid that it resists the 
tendency to flexion that it retains the retroposed position. 

Lateral position, either right or left, is generally due to 
inflammation in the cellular tissue of the broad ligament. In 
the acute stage of inflammation the organ may be pushed to 
the side opposite to that on which the exudation occurs. As 
the condition becomes chronic, the inflammatory material con- 
tracts, and the uterus is drawn to the affected side. These 
displacements cause no special symptoms. The symptoms, 
when present, are due to the complications or conditions which 
have produced the displacement and are a consequence of the 
displacement. 

490. Diagnosis. — The situation of the displaced organ is 
recognized by bimanual examination. The fixed position and 
situation are usually sufficient to establish the diagnosis. In 
lateral displacement the organ is not in a median position, 
and on manipulation moves more readily toward the affected 
side. In a woman whose abdomen is very fat or the abdominal 
wall quite rigid, the posterior dislocation is often difficult to 
differentiate from retroversion. The introduction of the sound 
would afford information, but the advantage derived from 
determining the position is insufficient to compensate for the 
danger from its use. An assistant dragging upon the cervix 



DISPLACEMENTS OF THE PELVIC ORGANS. 



501 



with a tenaculum or vulsellum, while either the vaginal or rectal 
bimanual is practised, will generally afford a definite deter- 
mination as to the character of the malposition. 

491. Torsion. — Torsion is generally associated with either 
a retroposition or a lateral position, and is due to an irregular 
contraction of the portion of the broad ligament which has 
been subject to cellular inflammation. This contraction twists 
the uterus upon its axis, so that the cornua may be turned 
anteroposterior instead of being situated laterally. The entire 
uterus can be thus twisted, so that, upon inspection, the os. 




Fig. 374. — Anteversion of the Uterus. 



instead of being transverse, will present an oblique or nearly 
anteroposterior line. Torsion also results from the presence 
of growths in one or the other broad ligament or of an ovarian 
tumor to which the tube is adherent. As the tumor enlarges 
it drags upon the uterus and twists it. This lesion is frequently 
overlooked, and presents no symptoms of special importance. 
(Treatment, see page 547.) 

492. Anteversion. — In anteversion, the uterus is found 
with its fundus forward and the cervix directed backward or 
upward and backward. (Fig. 374.) The organ m.ay be fixed 
in the abnormal position by complications, such as inflamma- 



502 GYNECOLOGY. 

tion, which may cause adhesions between the fundus and an- 
terior parietal peritoneum, or more frequently in the cellular 
tissues about the uterus, the cervix, or in the uterosacral liga- 
ments. An inflammatory process of the uterosacral ligaments 
with a normal uterus will produce flexion, but when the latter 
organ is stiffened by long-continued inflammation, it causes 
anteversion. The uterus is considerably increased in size; its 
walls are thickened and often rigid and firm. The normal 
flexion has disappeared, and the canal is perfectly straight. 
This position of the uterus is caused by increase of weight, 
and in severe versions the fundus will lie forward upon the 
bladder or against the symphysis, while the cervix may be 
directed upward and backward. 

493. Etiology. — Any disorder which increases the weight 
of the uterus increases the tendency to an antedisplacement. 
When the uterus has been the site of previous inflammation, 
particularly a metritis, this displacement is necessarily an 
anteversion. Metritis, subinvolution of the uterus, pelvic cellu- 
litis, occurring in the posterior portion and in the utero-sacral 
ligaments ; flbroid growths in the fundus ; ovarian growths — all 
may cause this form of displacement. 

494. Symptoms. — Anteversion presents no characteristic 
symptoms. The symptoms are those which are associated with 
the complication by which it is produced. The patient may 
complain of a sensation of distress, from pressure upon the 
bladder, of frequent micturition, and of pain or a dull ache over 
the region of the symphysis. 

495. Diagnosis. — Anteversion is readily determined by bi- 
manual palpation. The cervix is situated high posteriorly, 
and often reached with some difficulty, while the uterine body 
can be traced forward and is found to rest upon the bladder. 
Not infrequently the fundus lies well against the symphysis. 
The situation of the fundus in the anterior portion of the ab- 
domen, the absence of any angle in the uterus, and its size, 
weight, and more or less immobility, definitely differentiate it. 

496. Treatment. — As we have already seen, anteversion is a 
symptom or sign rather than an actual disease. It is a develop- 
ment that arises as a natural consequence of increased weight of 
the uterus, and the treatment must necessarily be that which is 
applicable to the existing complication. The most common 
complication is inflammation, causing hypertrophy or hyper- 
plasia of the uterus, an irritative infiltration and proliferation 
of the tissue element. The inflammatory condition may exist 
with or without adhesions. The treatment of the condition, 
then, in the great majority of cases, is that of existing inflam- 
mation — hot vaginal douches, tampons medicated with agents 



DISPLACEMENTS OF THE PELVIC ORGANS. 



503 



which are expected to exert an influence in decreasing the 
size of the uterus. This decrease can frequently be accom- 
plished, to a considerable degree, by thoroughly dilating the 
uterine cavity with laminaria tents, and after their removal, 
swabbing the interior of the organ with tincture of iodin, a sat- 
urated solution of iodin crystals in 95 per cent, carbolic acid, 
or a saturated solution of iodoform in ether. Following such 
an application the decrease in size of the uterus may still further 
be promoted by packing 
the organ with iodoform 
gauze and by placing a 
tampon of iodoform gauze 
beneath it. This raises the 
organ to a higher level and 
promotes its circulation. 
Furthermore, the uterus 
can be dilated with gradu- 
ated bougies, its cavity 
cureted, and applications 
made as suggested. Where 
the uterus is free from ad- 
hesions, it may be sup- 
ported by a pessary. The 
pessaries which were de- 
vised for the purpose of 
elevating the fundus have 
not proved satisfactory. 
The retroversion pessary 
in some cases of heavy 
uteri is particularly ser- 
viceable, although it may 
seem a paradoxical instru- 
ment to employ in ante- 
version, but it does, how- 
ever, afford relief by hold- 
ing the uterus at a higher 
level. Pelvic massage em- 
ployed daily is of special 

value in promoting drainage, in facilitating metabolism, and 
in decreasing the size of the uterus. Operations upon the 
cervix, amputation, or the repair of a laceration of the cervix 
will establish a process of metabolism which will decrease the 
size of the uterus. When the uterosacral ligaments have not 
become shortened through inflammatory processes and thus 
caused an irremediable displacement, the operation devised by 
Sims may be practised. This consists in making a transverse 




^^S- 375- — Sims' Operation for Anteversion. 



504 



GYNECOLOGY. 



denudation upon the anterior lip, another upon the anterior 
vaginal wall at a suitable distance from it, and uniting these two 
surfaces by sutures (see Fig. 375). As a result of this operation 
the cervix is drawn toward the vulvar outlet, the fundus is 
tilted upward, and a more correct position is secured. When 
the uterus is fixed by adhesions, in addition to the treatment 
already suggested, pelvic massage will prove beneficial. Two 
fingers in the vagina are hooked behind the cervix and press 
the fundus of the organ upward; while the external hand is 
rotated over the fundus, the fingers pressing down along its sides 
and in front of it, push the fundus backward. While the fundus 
is pushed backward with the fingers of the external hand and 
drawn forward with the fingers in the vagina, bands of adhesion 
are put upon the stretch and are manipulated to such an extent 
that their absorption is promoted. The manipulation of the 
uterus promotes absorption of inflammatory exudate within its 
walls, and thus assists in decreasing its size, so that by the 

time the adhesions are 
stretched and loosened, the 
uterus is so reduced in 
size that the patient is 
much relieved. In some 
cases, where a boring pain 
is experienced over the 
symphysis, the wearing of 
a cincture or belt (Fig. 376) 
will support the abdomi- 
nal viscera and relieve the 
degree that the ache or dis- 




Fig. 376. — Abdominal Belt. 



intra-abdominal pressure to such a 
comfort will disappear. 

497. Retroversion.— In retroversion the uterus is turned with 
the fundus backward. (Fig. 377.) The cervix is directed forward 
against the posterior wall of the bladder. This displacement 
varies in degree according to the relations of the cervix and uterus 
to the axis of the vagina. The maximum degree is a backward 
displacement in which the fundus lies low in the hollow of the 
sacrum, with the cervix directed upward. Retroversion is recog- 
nized as an early stage of prolapsus. With this displacement 
the intra-abdominal pressure is directed upon the fundus or upon 
the anterior wall of the uterus, which favors downward displace- 
ment, so that we usually find retroversion associated with a 
•certain amount of descent of the uterus. 

498. Etiology. — The most frequent cause of retroversion 
is a lesion of pregnancy. Retroversion occurs in the unmarried 
or sterile woman, but much less frequently. It is produced 
by decreased support of the ligaments, particularly of the 



DISPLACEMENTS OF THE PELVIC ORGANS. 



505 



uterosacral, which permits the uterus to sag downward and 
to be rotated backward; the latter action is occasioned by a 
distended bladder, until finally the ligaments lose their mus- 
cular tone and the organ does not regain its normal position. 
Retroversion can be produced by traumatism, as when the 
person falls from a height and strikes upon the feet or, par- 
ticularly, upon the buttocks, and by the presence of growths 
in the uterus or in the ovaries. 

499. Symptoms. — Retroversion causes few symptoms. The 
discomfort in the majority of cases arises from complications. 
Patients may have marked retroversion without experiencing 




Fig. 377. — Retroversion. 



any inconvenience or being aware of the condition until it is 
brought to their knowledge. Inflammatory complications pro- 
duce a sensation of weight or dragging, as if everything were 
about to protrude when the patient stands or walks. The 
menstrual flow is increased, producing menorrhagia; occasion- 
ally there is an irregular, bloody discharge, or the intermen- 
strual intervals are shortened, or, as a result of the coexisting 
catarrh, the patient will have a profuse leukorrhea. The pro- 
jection baclavard of the fundus and pressure of the cervix 
against the bladder cause a more or less frequent desire to 



506 GYNECOLOGY. 

urinate. Not infrequently there is an extension of the inflam- 
mation to the vesical mucous membrane, which produces cystitis. 
Pressure of the uterus upon the rectum increases the tendency 
to constipation, interferes with the rectal circulation, and 
develops hemorrhoids and fissure of the anus. An injury 
of the anus or rectum under these circumstances is slow to re- 
cover, which makes it important, in cases of rectal disease, 
to ascertain the condition of the uterus before we resort to 
any operative interference. 

500. Diagnosis. — Digital examination discloses the cervix 
uteri in the axis of the vagina, or looking forward and sometimes 
upward. Through the posterior vaginal fornix the examining 
finger recognizes a mass which is continuous on a straight line 
with the cervix. The bimanual examination discloses the 
absence of the fundus from the anterior fornix. The rectal 
bimanual affords an opportunity to explore the fundus and 
even the anterior surface of the uterus. (For treatment see 
Retroflexion, Section 571.) 

501. Lateral Version. — Lateral version is a form of dis- 
placement in which the fundus is situated to one side of the 
pelvis, while the cervix is directed toward the other. This 
condition is produced by cellulitis in the broad ligament and 
by intraligamentary growths, either fibroid or ovarian; in 
marked cases of inflammation contraction can occur in the 
base of one broad ligament and in its upper part on the op- 
posite side. This produces a fixation of the uterus directly 
transverse to the pelvis, not unusually with a certain amount 
of torsion. The lateral version causes no special symptoms, 
and is readily recognized by a bimanual palpation. 

502. Anteflexion. — In anteflexion the uterus is bent upon 
its axis, with the fundus forw^ard, while the cervix lies more 
or less in the axis of the vagina. The flexion may be slight 
(Fig. 378), but little more than normal; indeed, any flexion 
which is fixed is an abnormal one, even though it may not be 
greater than the ordinary bending of the uterus. From a slight 
flexion we may have a very acute one (Fig. 379), in which the 
fundus and cervix seem to lie upon each other at a very acute 
angle. The anterior wall of the uterus, at the point of flexion, 
undergoes a change in which there is a substitution of fibrous 
tissue for the muscle-wall. The posterior surface becomes 
exceedingly thinned where it bends over the anterior. (Fig. 
382.) The anteflexion ma}^- be mobile or immobile. The former 
results from a heavy fundus when the cervix is in a more or less 
fixed position. Raising the fundus, we can tilt it backward, and 
leave the uterus in a position of retroflexion, so that at times 
the organ is anteflexed; at others, retroflexed. Not infre- 



DISPLACEMENTS OF THE PELVIC ORGANS 



507 




pig^ 278. — Slight Degree of Anteflexion. 




Fig. 379. — Acute Anteflexion. 



508 GYNECOLOGY. 

quently a diagnosis of anteflexion will be made, and at a 
subsequent examination by another person the uterus is found 
retroflexed. If the fact that the organ is mobile is not remem- 
bered, an error in diagnosis will be attributed to the first investi- 
gator. In the immobile uterus the flexion is fixed. Anteflexion, 
again, may be regarded as physiologic, pathologic, and indifferent. 
A physiologic anteflexion is one which corresponds to the normal 
condition of the uterus; a pathologic, one in which the flexion is 
more or less fixed or is greater than normal ; while in an indif- 
ferent anteflexion the bending causes no symptoms. 

503. Etiology. — Anteflexion is probably next to the most 
frequent form of uterine displacement, and it occurs less fre- 
quently in the married than do the retrodisplacements. It 
occurs with greater frequency in the unmarried or nulliparous 
woman, and is a result of congenital conditions, or, rather, 
those which are associated with the earlier development of 
the uterus. Anteflexion may be ascribed, first, to the long 
cervix of the puerile organ, the situation of which, in the vagina, 
necessitates the fundus bending forward over it. Second, 
inflammation in the uterosacral ligament or in the cellular 
tissue posterior to the uterus, which draws the cervix upward 
(Fig. 383), promotes, in a flexible body, its falling forward, 
and the angle between the body and the cervix is increased. 
Third, the displacement arises from localized inflammation 
at the site of the placenta, when situated upon the posterior 
uterine wall. Involution is more rapid in the anterior, and 
the shorter wall becomes the string of the bow which bends 
the uterus forward. Fourth, anteflexion is produced by growths 
in the fundus of the uterus. 

504. Symptoms. — The symptoms most frequently attributed 
to anteflexion are sterility and dysmenorrhea; but when un- 
complicated by inflammation, neither of these symptoms is 
necessarily present. The patient with marked anteflexion 
generally suffers from chronic vesical distress. Pain occurs 
when the bladder is moderately distended, micturition is fre- 
quent, and generally there is a sensation of distress and annoy- 
ance which follows the evacuation. These symptoms, how- 
ever, are not infrequently produced by inflammation in the 
bladder, so that, as a rule, the urine should always be carefully 
examined. Dysmenorrhea has been attributed to an obstruc- 
tion of the canal from which there is an accumulation of material 
within the uterine cavity, and the organ has to go into labor 
to expel it. As flexion does not cause dysmenorrhea when 
the lesion is uncomplicated by inflammation, it is evident that 
the latter is the cause of the symptom, and that the hyperemia 
prior to and coincident with menstruation produces pain during 



DISPLACEMENTS OF THE PELVIC ORGANS. 509 

the distention of the inflamed surfaces rather than an obstruc- 
tion of the canal. Even in the congenital conditions the dys- 
menorrhea does not occur with the first menstruation, but 
later, when there is distinct evidence of the development of in- 
flammatory trouble. 

505. Diagnosis. — Anteflexion is recognized by digital and 
bimanual palpation. The cervix is situated in the axis of 
the vagina, and, by carrying the finger in front of it, a body 
is felt in the anterior fornix of the vagina, between which and 
the cervix a distinct angle is recognized. During bimanual 
palpation this angle can to some degree be straightened, and 
the relation of the flexion to the cervix and body is more 
distinctly recognized. The flexion is particularly determined 
by passing the index-finger into the lateral fornix, first upon 
one side and then upon the other; by pressing from above 
we are able to recognize the lateral borders of the uterus and 
the absence of an}^ growth. We can be in doubt as to whether 
the mass found in front is the fundus uteri or a fibroid growth 
attached to the anterior wall. Each condition may afford 
an equal-sized angle. The method we have already described, 
of passing the finger along the lateral aspect of the uterus, 
will enable us to differentiate them. By changing the position 
of the organ and pressing it well forward with the hand over 
the abdomen, we can outline the posterior surface of the fundus, 
and determine that its size and relations correspond to those 
of the cervix to the fundus, rather than to a growth. When 
the uterus is fixed, bimanual palpation is difficult. The posi- 
tion of the organ can be determined by the introduction of a 
uterine sound into the canal. The use of the sound, however, 
under these or any other circumstances, is fraught with so 
much danger that it is preferable to administer, if necessary, 
an anesthetic for the further practice of the bimanual, rather 
than to make an intra-uterine exploration. 

Rectal palpation with the digital finger, while the thumb 
of the same hand is placed in the vagina against the cervix, 
and the other hand over the abdomen, enables us to bring 
the uterus definitely under observa.tion. 

506. Treatment. — Anteflexion requires treatment only when 
it is associated with symptoms, and these are usually the re- 
sult of complications. The symptoms may be caused by com- 
plications incident to changes in the structure of the uterus 
itself, as inflammation either in the wall of the organ or in the 
surrounding structures. It may be incident to the various 
constitutional conditions, as a rheumatic or gouty diathesis, 
the effect of neurasthenia, but in such cases the treatment 
may be constitutional or a combination both of constitutional 



510. GYNECOLOGY. 

and local measures. The most frequent symptoms associated 
with this displacement are those of dysmenorrhea or painful 
menstruation, and sterility. That these symptoms, however, 
are not necessarily the result of anteflexion alone is evident, 
from the many cases in which the patients with marked ante- 
flexion have both menstruated painlessly and given birth to 
children. Patients suffering from dysmenorrhea associated 
with anteflexion should be encouraged to live an outdoor life. 
Hygienic measures are particularly important. The clothing 
should be suitable, and the extremities be warmly clad. Very 
frequently women who suffer from d^^smenorrhea while in 
our northern climates, will be absolutely free from this symptom 
when residing in the South or in the Bermuda Islands. Meas- 
ures should be instituted to improve the general nutrition, 
to obviate the sluggish circulation, to regulate the bowels. 
Such patients are often improved by bicycle-riding, playing 
golf, and anything which leads to an outdoor life. Pelvic 





Fig. 380. — Thomas Anteflexion Pes- Fig. 381. — Stem-pessary, 

sary. 

or uterine congestion should be decreased by the administration 
of iodids and bromids, the employment, particularly, a few 
days to a week before the menstrual period, of gelsemium or 
Pulsatilla, taking five drops of the fluidextract of gelsemium 
or ten drops of tincture of Pulsatilla, three or four times in the 
twenty-four hours, until the patient exhibits signs of its physi- 
ologic action. Thyroid extract has proved of value in these 
cases, when the drug is given in doses of three to five grains 
two or three times in the twenty-four hours. Douches, tam- 
pons, painting the vault of the vagina with tincture of iodin, 
gauze packing, and pelvic massage are all of service. The 
pessary, particularly the Graily-Hewitt (Fig. 367) or the Thomas 
anteflexion pessary (Fig. 380), which tilts up the fundus of the 
uterus, have had their advocates. Their efficacy, however, 
is somewhat doubtful. Pelvic massage is of special value in 
these cases, as the manipulation of the uterus serves to straighten 
the organ and promote a healthy condition of its circulation. 



DISPLACEMENTS OF THE PELVIC ORGANS. 



511 



When the patient is not improved by douches, tampons, or 
constitutional measures, the uterus may be dilated by the in- 
troduction of a laminaria tent. This procedure should be done 
under most thorough aseptic 
precautions, with the vagina 
thoroughly cleansed, the cervi- 
cal canal rendered as aseptic as 
possible, and the tent itself ster- 
ilized, preferably by dry heat. 
However, the tent may be 
placed for several minutes in a 
solution of iodoform and ether, 
in equal parts of alcohol and car- 
bolic acid, or, better, in iodin 
tincture prior to its introduction. 
The cervix should be seized with 
a double tenaculum, sponged 
with a solution of formalin, and 

by traction straightened so that the tent can be the more readily 
introduced. As large a tent as the caliber of the cervical canal 




Fig. 382. — Section Showing Thinning 
of Cervical Walls at the Angle of 
Flexion. 




Fig. 383. — Anteflexion Associated with Contraction of Uterosacral Ligaments. 

will allow should be employed. The tent is removed in from 
twelve to fourteen hours, after which the uterine cavity is irri- 



512 GYNECOLOGY. 

gated, if necessary cureted, swabbed with a saturated solution 
of iodin in carbolic acid or of iodoform in ether. The canal may 
or may not be packed with iodoform gauze. The dilatation 
with tents may be repeated at intervals until the tendency 
to displacement appears to be overcome and the complicating 
involvement of the uterus has subsided. Inflammation in the 
cellular tissue about the uterus, or in the tubes and ovaries, 
as evidenced by their being enlarged and fixed in the pelvis, 
should be considered a contra-indication to the employment 
of tents. The dilatation can be accomplished by graduated 
bougies and their employment followed by curetment. Twenty- 
five years ago the employment of the stem-pessary was a favorite 
method of overcoming an anteflexion. The stem was one- 
eighth of an inch shorter than the uterine cavity; the patient 
was required to wear it for a considerable length* of time. (Fig. 
381.) The objection to the stem-pessary is that it is a source 
of irritation, affords constant danger of infection to the uterine 
mucosa, and may lead to the development of more serious 
trouble. W. Gill Wylie advocated the employment of a grooved 
stem of hard rubber or glass which should serve as a drainage- 
tube. He and others still practise this method of overcoming 
the dysmenorrhea incident to acute anteflexion and claim 
marked improvement in many cases. The favorite treatment of 
Sims was a bilateral incision — occasionally one through the 
posterior lip. Unless precautions are taken to prevent union, 
the parts are reunited. Even when precautions are employed, 
cicatricial tissue forms, which subsequently causes distress, some- 
times greater even than the preexisting condition. The pos- 
terior lip can be split up to the angle of flexion and its cervical 
and vaginal lining membranes united by sutures, to prevent re- 
union. Occasionally, after such an operation, the cervix spreads 
out, owing to the intra-abdominal pressure, and the more delicate 
cervical mucous membrane is thus exposed to pressure and 
irritation, resulting in endometritis and formation of cysts 
of Naboth, which will require continuous treatment. Splitting 
the anterior lip has been advocated. This is performed by 
dissecting the bladder from the anterior wall of the cervix to 
the level of or above the point of flexion. A grooved director 
is then introduced into the uterus and the cervix is incised. 
As the incision approaches the os it is carried around to the 
side of the cervix. The cervical mucous membrane is united 
to that of the vaginal wall. This enlarges the opening from 
the front and prevents obstruction, but is subject to the same 
objection made to the posterior operation, in that it exposes 
delicate surfaces to irritation and subsequent inflammation. 
E. C. Dudley has devised an ingenious operation, in which he 



DISPLACEMENTS OF THE PELVIC ORGANS. 



513 



splits the posterior lip beyond the vaginal attachment; the 
surfaces are held apart by tenacula and the incision is deepened 
upon the cervical side with a knife. A wedge-shaped piece is 
removed from each side, and the sutures are so introduced 
as to unite the edge or apex of the incision on each side with 
the base. By this method eversion of the cervical mucous 
membrane is prevented. (See Fig. 384.) The anterior lip 




Fig. 384. — Dudley's Operation for Anteflexion, by Incising and Suttiring the 

Posterior Lip. 



of the cervix is then amputated, and the wound closed with 
transverse sutures, which push back the cervical orifice and 
straighten the canal. (See Fig. 385.) Nourse, recognizing 
that the flexion corresponded to the shorter wall, made a bi- 
lateral incision to the level of or a little above the angle of 
flexion. Traction is then made upon the posterior lip, which 
results in straightening the canal. The new surfaces are apposed 
and secured with sutures, leaving the posterior lip longer. When 
33 



514 



GYNECOLOGY. 



the latter is half an inch or more in length, it is amputated by 
the flap method, thus making it the same length as the anterior 
lip. The raw surfaces are united b}^ suture. (Figs. 386 and 
387.) When the . elongation is short, it is left to contract. 
C. A. L. Reed advocated opening the abdomen and removing 
a wedge-shaped piece from the posterior wall of the uterus 
opposite the angle of flexion. This surface is closed by vertical 





Fig. 385. — Completion of Dudley's Operation, by Transverse Denudation and 
Suturing of the Anterior Lip. 



sutures and restores the organ to normal position. Burrage 
advises, in proper cases, incision of the uterosacral ligaments 
and the performance of a ventrosuspension, thus raising the 
fundus of the organ upward. 

507. Retroflexion. — In retroflexion the fundus is bent back- 
ward upon the uterine axis, and, according to its degree, lies 
toward the rectum (Fig. 388) or is forced well down into Douglas' 



DISPLACEMENTS OF THE PELVIC ORGANS. 



515 



pouch. (Fig. 389.) The cervix is in the axis of the vagina. The 
retroflexion may be mobile or immobile, may be pathologic 




Fig. 386. — Nourse's Operation by Splitting the Cervix and Resuturing the 

Incisions. 




Fig. 387. — Operation Completed. 



or indifferent, but can never be said to be physiologic. This 
form of displacement is very frequently a sequel of version. 
The uterus becomes retroverted and the abdominal pressure 



516 



GYNECOLOGY. 



then drives the fundus downward, bending it upon its axis, 
forcing it into Douglas' pouch. (Fig. 390.) 

508. Etiology. — Retroflexion is produced by metritis; sub- 
involution; inflammation of the placental site, in the anterior 
wall of the organ; fibroid growths in the fundus or anterior 
uterine wall (Fig. 391), parametric inflammation, or cellulitis of 
the anterior segment of the pelvic floor, which draws the cervix 
forward; localized peritonitis; or contraction following hemato- 




Fig. 388. — Retroflexion of Slight Degree. 



cele (Fig. 392), by which the fundus of the organ is drawn back- 
ward. 

509. Symptoms. — Retroflexion, like the other forms of dis- 
placement, when uncomplicated presents no special symptoms. 
It produces a sensation of weight and pressure, not infre- 
quently pain in the region of the anus, an uncomfortable sen- 
sation down the posterior surface of the lower extremities, 
points of anesthesia over the thighs, congestion, partial ob- 
struction of the rectum, obstinate constipation, and not infre- 
quently a sensation that the intestine is so obstructed that the 



DISPLACEMENTS OF THE PELVICXORGANS. 



517 




Fig. 389. — Retroflexion of Extreme Degree. 




Fig. 390. — Retroflexion Following Version. 



518 



GYNECOLOGY. 



bowel can not be evacuated. Development of hemorrhoids, 
anal fissures, and more or less prolapse of the rectal mucous 
membrane not unusually follow. Menstruation is irregular and 
profuse, or the menstrual intervals are shortened, and leukor- 
rhea is quite profuse. 

510. Diagnosis. — Digital examination discloses the cervix 




Fig. 391. — Retroflexion Produced by Fibroma of Anterior Uterine Wall. 




BLADDER. 



Fie. 



39: 



-Retroflexion the Sequel of Inflammatory Adhesions. 



situated at a lower level in the pelvis, occupying the axis of 
the vagina or directed a little anteriorly; the finger in the pos- 
terior fornix recognizes a body slightly above, or even below, 
the cervix, which is rounded, may be movable or fixed, and 
somewhat larger than the normal fundus. Between it and the 



DISPLACEMENTS OF THE PELVIC ORGANS. 



519 



cervix is a distinct angle, though the structures can be traced 
from one to the other. The finger in the anterior vaginal fornix 







^' 



Fig. 393. — Retroflexion Simulated b}^ Posterior Uterine Myoma. 




Fig, 394. — Retroflexion Simtflated by Small Ovarian Cyst in Posterior Culdesac. 



and the other hand over the abdomen discloses the absence 
of the fundus uteri from its normal position. The flexion is 



520 



GYNECOLOGY. 



apparently increased by pressure upon the cervix, and the fundus 
is driven more deeply into the culdesac. By pressing the 
finger upward on either side of the uterus and cervix the lateral 
margins can be determined. Digital examination through 
the rectum enables us to pass directly over the fundus and 
to feel to some degree its anterior surface, which now becomes 
posterior. Retroflexion of the uterus can be confounded with 
fibroid growths (Fig. 393) situated in the posterior uterine wall, 
adherent ovarian growths (Fig. 394), and pelvic inflammatory 
exudation. (Fig. 395.) The introduction of the sotmd into 
the uterine canal, and its passage backward into the mass, 
would be definite evidence that a retroflexion exists; but, as 




Fig. 395. — Anteflexion and Retroflexion Simulated by Pelvic Exudation. 



in other uterine conditions, this procedure is fraught with so 
much danger that it is preferable to make the diagnosis with- 
out it, and, if necessary, even to leave it uncertain. With 
a careful bimanual examination, as has been advised, by the 
rectum, the vagina, or both, we are generally able to deter- 
mine the relations of the uterus to the surrounding parts, and 
absolutely to fix the diagnosis. When the existence of pelvic 
exudate or immobility of the uterus and a resistant or thick 
abdomen prevent its accomplishment, the patient should be 
given an anesthetic. 

511. Treatment of Retroversion and Retroflexion. — As retro- 
flexion is simply a bending of a version, we will, therefore, con- 



DISPLACEMENTS OF THE PELVIC ORGANS. 



521 



tsider the treatment of these two conditions together. As 
the majority of the other displacements are not characterized 
by symptoms, unless complications are present, so, in these 
•conditions, symptoms are not manifest without the existence 
•of complications. The organ, however, in maintaining a retro- 
position, interferes with its circulation, which results in con- 
gestion and subsequently in more or less inflammation. There- 
fore the treatment of the complications is ineffective so long 
.as the displacement remains. The relief of the inflammatory 
■condition is expedited by maintaining the uterus in a correct 
position. Treatment largely depends upon the duration of 
the displacement, the changes which the structures have under- 




Fig. 396. — The Retro verted Uterus Replaced; Patient in Dorsal Position. 

:gone, and the ability of one to replace and maintain the organ 
in proper position. No means for maintaining the uterus in 
position are effective until it has first been accurately replaced, 
after which it can be supported with relief of many of the dis- 
tressing symptoms. Three methods are generally recognized 
as proper for replacing the organ. These are: (i) The bimanual. 
The patient is placed in the dorsal position with her limbs 
flexed. Two fingers are introduced into the vagina, while the 
fingers of the other hand are placed over the abdomen (Fig. 
396). The middle or long finger is passed into the posterior 
fornix of the vagina to press up the fundus, while the index- 
finger is carried in front of the cervix to push it backward. 



522 



GYNECOLOGY. 



The pressure against the lower end of the lever carries the 
opposite end, the fundus, forward, until it can be grasped by 
the external hand and brought into a position of ante version. 
In some cases the fundus of the uterus is caught beneath the 
promontory of the sacrum and can not readily be dislodged. 
If the cervix, however, is grasped with a double tenaculum 
or vulsellum, and drawn down, while the fundus is pushed up 
with the finger in the vagina or rectum, the fundus uteri is 
readily displaced from beneath the promontory and the cervix 
can then be carried backward. The second procedure con- 
sists in placing the patient in the genupectoral position and 
the employment of the Sims speculum to open the vagina. 
The atmospheric pressure balloons the vagina and the uterus is 




Fig. 397. — Schultze's Method of Replacing an Adherent Retroverted Uterus. 



carried to the upper part of the canal. This procedure, how- 
ever, does not of itself correct the position, as the uterus, though 
elevated, may still be retroflexed or retroverted. The posi- 
tion, when uncomplicated, may be readily corrected by seizing 
the cervix with a tenaculum or vulsellum, and drawing it to- 
ward the vaginal orifice, and then carrying it backward and 
upward. The fundus is thus dislodged and the position corrected. 
A third procedure consists in the employment of the uterine 
sound. With the patient in the dorsal position, two fingers are 
introduced into the vagina and the sound, carried between 
them, enters the os and is introduced to the fundus and then 
rotated. The external end of the sound is carried through 
a wide arc so as to do as little injury to the internal mucous 
membrane as possible, while the handle of the sound is de- 



DISPLACEMENTS OF THE PELVIC ORGANS. 



523 



pressed and the finger in the posterior fornix pushes the fiindus 
upward. This combined movement carries the fundus for- 
ward until it can be controlled with the external hand. In 
spite of the most careful precautions, the uterine mucous mem- 
brane will be injured by this method of procedure. It is ex- 
ceedingly difficult to avoid the danger of the introduction of 
infectious material into the uterus, which necessarily favors 
the development of further complications. For such reasons, 
the sound should not be employed, especially as every purpose 
attained by its use can be readily accomplished by the employ- 
ment of the dorsal manipulation or with the patient in the 
genupectoral position. Various jointed sounds have been 




Fie 



-Second Step in Replacing Uterus by Schultze's Operation. 



devised for the purpose of replacement of retrodisplaced uteri, 
but these instruments are open to the same objections offered 
to the use of the ordinary sound. 

In adherent uteri none of these methods of procedure will 
accomplish the restoration of the displaced organ. When 
the adhesions exist between the posterior uterine surface and 
the anterior rectal wall, the intestine may be dragged up with 
the uterus and apparently permit it to assume its normal posi- 
tion; but as soon as the supporting force is removed, the uterus 
is drawn back and, if mechanical efforts are employed to main- 
tain it in position, the fundus is bent backward and the retro- 
flexion is greatly increased. If adhesions are present and they 



524 GYNECOLOGY. 

are not too firm and of too long duration, pelvic massage affords 
a valuable method for overcoming their baneful influence and 
promoting their absorption. The massage should be supple- 
mented by the use of tampons. In some cases the pressure 
of an air pessary within the vagina stretches the bands of ad- 
hesions, promotes their absorption, and supports the uterus. 
Schultze advocated a procedure which is very effective in over- 
coming recent adhesions. The patient is placed in the dorsal 
position, with the muscles well relaxed by an anesthetic. Two 
fingers are introduced into the rectum, while the thumb in the 
vagina against the cervix steadies the uterus until the rectal 
fingers, one on either side of the fundus, can invert and draw 
down the bowel and separate it from the uterine surface (Figs. 
397 and 398). As the adhesions are separated and the uterus 
is set free, the external hand grasps the fundus and draws it 
forward, after which the remaining bands of adhesion are broken 
up. Care must be exercised in carrying out this procedure 
not to employ too much force, otherwise the intestine may 
very readily be injured. There is more danger, however, of 
injuring the tubes or ovaries, when these organs are adherent. 
An adherent tube may be torn and -liberate poison at the seat 
of inflammatory trouble, which, particularly if of a purulent 
character, would be followed by a violent attack of pelvic or 
possibly general peritonitis. With purulent inflammation or 
pus collections in the tube excluded, the absorption and loosen- 
ing of the adhesions of the ovary, tube, and uterus can be 
effected by pelvic massage. If the adhesions are extensive and 
the vagina tender, especially when its posterior fornix is more 
or less obliterated by the long duration of the displacement, 
the uterus can be temporarily supported by the employment 
of vaginal tampons, medicated or not, as the conditions require. 
The employment of continual pressure over the abdomen or 
within the vagina may be effected by shot-bags or the employ- 
ment of rubber bags containing mercury. Three to five pounds 
or ,more of shot may be applied over the abdomen to make 
pressure over a mass of exudate and thus promote its absorp- 
tion and the setting free of an adherent uterus. The absorp- 
tion of the vaginal exudate may be expedited by the use of 
mercury, applied in a rubber bag. Such a weight introduced 
into the vagina, with the position of the patient changed from 
time to time in order to subject different portions of the exudate 
to the weight, promotes its absorption and the consequent loosen- 
ing of the uterus and pelvic structures. 

When the uterus is free from adhesions and, consequently, 
can be readily replaced, we can at once resort to the use of a 
pessary. Some of the more prominent retrodisplacement pes- 



DISPLACEMENTS OF THE PELVIC ORGANS. 



525 



saries are the Hodge (Fig. 362), Thomas, Munde (Fig. 363), 
and the Schtdtze (Fig. 399) instruments. The various modi- 
fications of the Hodge pessary consist of a posterior bar with 
converging side bars which are united 
by a shorter bar anteriorly. Laterally, 
the pessary has the shape of a letter S- 
The posterior bar is carried behind the 
cervix into the posterior fornix. In 
its modification by Thomas and 
Munde, the posterior bar is thick- 
ened, which makes a larger mass in 
the fornix. The pessary does not 
support the body of the uterus on 
its posterior bar, but it so drags upon 
the posterior vaginal fornix as to ptdl 
against the cervix and lift it up, until the other end of the 
lever — the fundus — is held so far forward that the intra- 
abdominal pressure is directed upon the posterior uterine sur- 




Fig. 399. — Schultze Pessary. 




Fig. 400. — Proper Position of the Pessary. 



face. This pulley-like action of the pessary is readily seen 
in Fig. 400, which shows the proper position of the pessary 
in relation to the uterus and vagina. It has already been 
emphasized that the pessary does not support the body of the: 



526 



GYNECOLOGY. 



uterus, and that the position of the organ must be corrected 
before the introduction of the instrument. The result of an 
attempt to employ the pessary to correct the position of the 
uterus can be seen in Fig. 401. It is very important that the 
pessary should not be unduly long. When too much pressure is 
produced, ulceration of the vagina occurs, rendering the pa- 
tient unable to retain it, or, if the instrument is too long, it 
may project from the vulva and cause irritation about the urethra 
or neck of the bladder, and much discomfort in sitting. The 
proper length of the pessary is readily determined by the intro- 
duction of two fingers into the vagina to measure the distance 




Fig. 401. — Faulty Position of the Pessary. 



between the distended posterior vaginal fornix and the internal 
margin of the symphysis. The proper width of the pessary 
is appreciated by determining the extent to which the fingers 
can be separated without undue lateral presstire in the vagina. 
The proper size of the instrument to be employed is thus as- 
certained. While a pessary too long produces the conditions 
we have already mentioned, one too short allows the fundus 
of the uterus to fall backward over its posterior bar and in- 
creases the retroflexion and adds to the distress of the patient. 
It is difficult to maintain the pessary in place where the vagina 
is much relaxed. If the uterosacral ligaments are much elon- 



DISPLACEMENTS OF THE PELVIC ORGANS. 527 

gated, and the posterior fornix distensible, the pessary will 
fail to maintain the uterus in its normal position, and, more- 
over, it will permit the organ to drop back and rest upon the 
instrument. (Fig. 401.) Schultze designed the pessary known 
as the figure-of-8, which is very effective for such cases. This 
pessary laterally is similar in shape to the Hodge instrument, 
forming a letter S. The lateral bars of this pessary are twisted 
to form a figure-of-8, the upper loop of which surrounds the 
neck of the cervix and carries it upward, while the inferior loop 
is so broad that it receives support from the vagina and does 
not incline to prolapse. Should the figure-of-8 prove un- 
satisfactory, the sledge pessary of Schultze may be efficient. 
(Fig. 402.) Its posterior end has a bar curved forward, which 
rests in front against the cervix and holds it back, while at 
the same time traction is made upon the cervix through the dis- 
tention of the posterior fornix by the upper part of the instru- 
ment. The pessary should be sufficiently broad to impinge 
against the side walls of the vagina to 
prevent it being displaced downward. 
It distends the vagina in three direc- 
tions — in length, laterally, and in 
the anteroposterior direction. When 
adhesions are present, the pessary is 
badly borne and is harmful. It is at 
all times a foreign body and produces 
a certain amount of irritation in the 
vagina, which, to many patients, is Fig. 402.— Schultze's Sledge 
a source of much discomfort; besides. Pessary. 

it is not always efficient in maintain- 
ing the uterus. It must be worn for months or even years to 
secure sufficient contraction to maintain the organ, consequently 
many patients prefer to submit to operative interference. 

The pessary may be employed in retroversions due to sub- 
involution of the uterus subsequent to a recent delivery. In 
such cases the pessary will maintain the uterus at a higher 
level, promote the process of involution, and thus favor the 
maintenance of the organ in a replaced position after it has 
reached its normal size. It may be employed after adhesions 
have been broken up, by the Schultze method, or when we 
have been able to accomplish the loosening of the uterus by 
pelvic massage. Where retrodisplacement has existed for 
some time, the posterior fornix of the vagina may be so shortened 
that the pessary can not be worn. Such a condition will re- 
quire treatment by douches and tampons until the posterior 
vaginal fornix is stretched. They are also of little value in those 
cases in which the vaginal portion of the cervix has been des- 




528 



GYNECOLOGY. 



troyed by amputation or as a result of repeated labors. As 
the pessary is a foreign body, it is therefore important that 
explicit directions should be given regarding its management 
before this subject is dismissed. Directions have been given 
for the determination of a suitably sized instrument, and I 
would again emphasize the fact that the instrument should 
be neither too large nor too small. The former will cause 
pressure upon the surrounding parts, producing irritation, 
ulceration, loss of structure, and open avenues for the entrance 
of infection. A smaller instrument is easily dislodged from 
its position, does not serve any useful purpose, and may only 
serve to aggravate the condition. The patient should be directed 



APONEUROSIS 
E;(T. OBLIQUE 



ROUNJ) 

LIGMT. 




3UB-CUTANE0U5 
FAT 



H 



mcvmi N. 



Fig. 403. — Alexander Operation; Round Ligament Exposed. 



to remove or have the instrument removed if it gives rise to 
increased discomfort, and return to the physician within a 
week at least after its introduction. He can then determine 
definitely whether the instrument is serving its proper purpose 
or causing any irritation. In neurotic patients too much at- 
tention must not be given to the instrument, otherwise the 
patient, will manufacture a long train of distressing symptoms 
and attribute them to its presence. The instrument is likely 
to increase the vaginal discharge, and for this reason it is im- 



DISPLACEMENTS OF THE PELVIC ORGANS. 



529 



portant that it should be kept clean. It is undesirable, how- 
ever, to employ mineral astringents in the douche for this 
purpose, as they are likely to become deposited upon the sur- 
face of the pessary, thus rendering it rough and, therefore, 
more likely to serve as an irritant. A properly fitting instru- 
ment can be worn by the patient without her being aware of 
its presence, but even though it causes no annoyance, the patient 
should be advised of the importance of having it removed at 




Fig. 404. — Round Ligament Being Drawn Out. 



stated intervals, not exceeding three months, for cleanliness, 
and to make sure that it is producing no irritation. These 
rules apply to the hard-rubber instrument. Where the in- 
strument is of the soft-rubber variety, it should be removed much 
more frequently, as the discharges to some degree enter into 
the rubber, decomposition takes place, and a foul odor arises 
which is very annoying to the patient and to those with whom 
34 



530 



GYNECOLOGY. 



she is associated; moreover, it ma}^ give rise to systemic 
infection. 

The operative procedures for the correction of retrodisplace- 
ments of the uterus consist of the extraperitoneal and intra- 
peritoneal shortening of the round ligaments, by abdominal 
or vaginal incision, and the construction of artificial ligaments, 
as in such operations as ventrofixation or ventrosuspension. 




il;. 405. — Round Ligament Sutured. 



Besides these, there are also numerous vaginal operative methods 
for correcting retroplaced uteri. 

Extraperitoneal Shortening of the Round Ligaments. — Shorten- 
ing of the roimd ligaments is an operation which was performed 
by Alexander in December, 1881, and two months later by 
Adams, although the latter contributed the first publication. 
The operation had, however, been advocated by a Frenchman 



DISPLACEMENTS OF THE PELVIC ORGANS. 



531 



named Alquie, as early as 1840. The operation requires two 
incisions, and each consists of four stages: (i) An incision six 
centimeters long, a little inside the pubic spine and above 
and parallel to Poupart's ligament, is made through all the 
tissues to the aponeurosis of the external oblique. (Fig. 403.) 
(2) Exploration for the round ligament. This is disclosed by 
a small ball of fatty tissue which covers its end between the 
pillars ot the external inguinal ring. Pressure upon the side 
causes the mass to pro- 
trude. A hook passed 
beneath this mass en- 
ables the operator to 
raise up the ligament. 
(Fig. 404.) It is then 
detached by a direc- 
tor, from the posterior 
adherent fibers which 
maintain its relation 
to the inferior part of 
the canal, after which 
it is seized with a pair 
of forceps and drawn 
out. Upon the com- 
pletion of the first and 
second stages, on both 
sides, we proceed to 
the third, which con- 
sists in shortening and 
fixation of the liga- 
ments. The ligaments 
are drawn upon until 
the fundus is brought 
under the pubes. This 
movement can be facil- 
itated and rupture of 
the fibrous filaments 
avoided by previously 
placing the uterus in 

anteflexion, either by the sound or preferably by the aid of the 
fingers of an assistant. The ligaments are drawn out from four to 
ten centimeters, according to the resistance. When they become 
tense, they are maintained by an assistant, while a needle charged 
with silk, silkworm-gut, or catgut is made to traverse the external 
pillar, theligament, and next the internal pillar. (Fig. 405.) Three 
sutures are thus introduced, one centimeter apart. (Figs. 406 
and 407.) (4) The wound is closed with silk or silkworm-gut 




Fi 



406. — Continuous Catgut Suture Uniting In- 
ternal Oblique Muscle to Poupart's Ligament. 



532 



GYNECOLOGY. 



sutures, dressed with gauze, and the parts are so secured by 
bandaging as to prevent the wound from becoming exposed by 
the movements of the patient. The employment of a Hodge 
pessary for two months following the operation is advisable, 
though some prefer the tampon. Various modifications of this 
operation have been devised. Edebohls splits the entire length 
of the inguinal canal, draws the ligaments out at the internal 




RD.LIGnT. 



Fig. 407. — Return Layer of Suture Bringing External Oblique Muscle in 

Apposition. 



ring, and closes the wound as in the Bassini operation. New- 
man makes an incision directly over the internal ring, draws 
the Hgament straight out, and secures it in the wound. Franklin 
Martin and Buret, of Lille, do not use sutures, but pass a pair 
of dressing forceps beneath the skin and subcutaneous tissue 
from one wound to the other, draw the ligament through, tie 
the two ligaments together in a knot, and close the tissues over 



DISPLACEMENTS OF THE PELVIC ORGANS. 533 

the union. Cassati joins the lower ends of the lateral wounds 
with a curved incision, in which the crossed ends of the liga- 
ments are united by continuous suture. Doleris employs the 
same method, uniting the two ligatures with catgut sutures, 
after pulling theiji through, as in the method suggested by 
Martin. Goldspohn attempts to extend the usefulness of the 
Alexander operation by stretching the internal ring and open- 
ing through the peritoneum, so that the finger can be passed 
into the pelvis and break up adhesions about the uterus, ovaries, 
and tubes. By this method a tube or ovary can be withdrawn 
and subjected to necessary treatment. The advantages claimed 




Fig. 408. — Wylie's Operation for Shortening the Round J^igaments within the 

Abdomen. 



for the Alexander operation are: (i) The incisions being super- 
ficial or extraperitoneal, the risk of infection is less; as it is 
local, the danger of peritonitis is decreased; (2) the method of 
maintaining the uterus forward has less injurious influence upon 
a future pregnancy; (3) it imitates the natural support, in that 
the natural ligaments are employed; and (4) no intraperitoneal 
adhesions can form. The disadvantages are: (i) That two 
incisions are reqmred. (2) The operation is limited in its ap- 
plication. It is only in those cases in which the uterus is mobile 
that we can practise this procedure. Consequently it has the 
further disadvantage in that we are not always able to deter- 
mine definitely the existence of adhesions between the uterus 
and the anterior wall of the rectum. Should such adhesions 
exist, the uterus drawn forward by the round ligaments is sub- 



534 



GYNECOLOGY. 



ject to forces which tend to render the operation nugatory. 
The procedure of Goldspohn seeks to overcome this objection; 
nevertheless, the objection still remains, for the operation to 
break up adhesions and treat the pelvic organs is done through 
so small an opening as to render it more or less a blind proce- 
dure. Besides, severe injuries may occur and be readily over- 
looked. (3) The roimd ligaments are sometimes so attenuated 
as to be of little use in maintaining the organ. In an operation 
of mine the ligament on one side was apparently entirely absent. 
I found no vestige of it in the canal. I therefore opened into 
the peritoneal cavity and found that the round ligament had 
disappeared. (4) In cases of infection the infected ligament 
may slip back and carry infection beneath the peritoneum, 




Fig. 409. — Mann's Operation for Intra-abdominal Shortening of Round Liga- 
ments. 



where it w411 be difficult to reach, and, consequently, render the 
operation, as has been proved, not altogether free from danger. 

Intraperitoneal Shortening of Round Ligaments. — The round 
ligaments are shortened within the peritoneal cavity by making 
an incision through the abdomen in the median line. This 
procedure permits the uterus to be drawn up, the condition of 
the appendages examined and treated, if necessary. Existing 
adhesions can be broken up and the round ligaments shortened 
by folding them. (Fig. 408.) Wylie suggests that from two to 
four inches of the ligament be doubled up on each side and united 
by sutures, so that the shortened ligament draws and holds 
forward the fundus. Mann grasps the broad ligament about 
the junction of its middle and outer third and folds the ligament 
in three parts which are united by sutures. (Fig. 409.) By this 



DISPLACEAIENTS OF THE PELVIC ORGANS. 



535 



method the Hgament is well shortened on each side. A. P. 
Dudley, of Ncav York, performed an operation which he called 
desmopycnosis. (Fig. 410.) This is accomplished as follows: 
The abdomen opened, an assistant introduces two fingers into 




Fig. 410. — Dudley's Operation of Desmopycnosis. 

the vagina and pushes the uterus as high as possible in the 
pelvis, while the operator brings the organ through the ab- 
dominal incision. An oval denudation is made upon the ante- 
rior uterine wall, making sure that the bladder is not injured; 




Fig. 



411 



■Dudley's Operation Completed. 



then each round ligament is brought up to the portion of the 
peritoneal covering on the inner side, denuded to correspond 
with that on the uterus, and the three denuded surfaces are then 
united with catgut sutures. The sutures must be so adjusted 
as to pass sufficiently deep in the uterine tissue to secure against. 



536 



GYNECOLOGY. 



their cutting out before union has occurred. (Fig. 411.) This 
procedure holds the uterus forward in a position of anteversion. 
Ries cuts a sHt through the anterior surface of the fundus, 
through which a loop of the round ligament, drawn out of its 
sheath, is carried and fastened on either side. Bissell excises a 
portion of the round ligament and unites the cut ends with cat- 
gut sutures. Webster picks up a loop of the round ligament, 
carries it through the broad ligament beneath the Fallopian tube, 
and secures it to the posterior surface of the uterus. This pro- 
cedure has been modified by Baldy, who ligates the uterine end 
of the round ligaments, incises each ligament external to the liga- 
ture, and carries the free end, rather than the loop, through the 
broad ligament and fastens it to the posterior surface of the 
uterus. All these operative procedures, however, act upon the 




Fig. 412. — Gilliam-Ferguson Operation. Round Ligament Seized through 

Stab Wound. 



strongest part of the ligament, leaving the weakest portion, that 
which occupies the inguinal canal, to be stretched out. Gilliam 
devised a procedure (Fig. 412) which consists in picking up the 
ligament, three or four centimeters from its uterine end, and 
carrying a loop of it through a stab wound in the lower part of 
the rectus muscle on either side, and there securing it. (Fig. 413.) 
This procedure divided the lower part of the abdomen into three 
apertures, through two of which coils of intestines were capable of 
being pushed and compressed to a greater or less degree. To ob- 
viate such danger Ferguson modified the operation by quilting to- 
gether the peritoneal surface external to the point transfixed by 



DISPLACEMENTS OF THE PELVIC ORGANS. 



537 




Fig. 413. — Round Ligament Drawn through the Abdominal WaU. 




% 
^ 



Fig. 414. — Section Showing Position of the Uterus with Completion of the 

Operation. 



538 



GYNECOLOGY. 



the loop of round ligament. This ligature, when tied, closes up the 
gap in the peritoneal cavity external to the point through which 
the loop of the ligament is brought out. With these parts secured, 
the uterus is held forward by a loop of the strongest part of the 
round ligament. (Fig. 414.) Simpson, through a median incision 
about one inch from the uterus, passed a suture through three- 
fourths of the round ligament, threaded both ends of this suture 
into a carrier, and through the slit made in the anterior layer of 




Fig. 415. — First Step in My Modification of the Gilliam Operation for Securing- 
Round Ligament Support. 



the broad ligament passed it directly forward beneath the peri- 
toneum of the vesico-uterine pouch to a point upon the anterior 
abdominal wall one and one-half inches external to the median 
line, and carried both ends into the peritoneal cavity, one end 
threaded into a sharp curved needle and thrust into the muscular 
structure, emerged upon the peritoneum, where it was secured by 
tying with the other end. I have combined the Simpson and 



DISPLACEMENTS OF THE PELVIC ORGANS. 



539 



Gilliam operation as follows: A cun-ed incision, when possible, 
within the pubic hair line is made through skin, superficial fascia, 
and aponeurosis. The aponeurosis is loosened from the pyra- 
midalis muscles and drawn upward (see Figs. 78 and 79), the 
recti muscles separated, and the peritoneum divided in the ver- 
tical line. After freeing adhesions and giving proper attention 
to the condition of the ovaries and tubes, a suture is passed be- 




Fig. 416. — Second Step, Showing Ligament Fixed with Hemostat while Tem- 
porary Ligature is Carried Beneath Anterior Leaflet of Broad Ligament 
with a Deschamps Needle. 

neath each roimd ligament, one inch and a half external to the 
uterus. (Fig. 415.) The ends of the suture upon one side are 
threaded into the eye of a Deschamps needle having a rather long 
arm. (Fig. 416.) The round ligament external to the suture is 
seized with a hemostat and giA'en to an assistant with the 
direction to keep it taut. An opening is made into the an- 
terior layer of the broad ligament, just below the insertion of the 
suture, and through this opening the needle carr^dng the ends of 



540 



GYNECOLOGY. 



the suture is introduced and carried outward between the layers 
of the broad ligament until the parietal peritoneum is reached, 
when the latter is drawn inward and the point of the instru- 
ment plunged through the abdominal parietes, emerging upon 
the aponeurosis. The suture ends upon each side, are withdrawn 
from the Deschamps needle, and the ends secured by a hemostat. 
Seizing the suture upon one side and drawing upon it to make it 




Fig. 417. — Operation Completed; Differs from Gilliam-Ferguson in Having No 

Internal Sutures. 



tense, a pointed scissors, closed, is thrust alongside the ligature 
and the blades separated, when, in the majority of cases, the trac- 
tion causes a loop of the ligament to follow the withdrawal of the 
scissors. Where it does not at once follow, it can be teased through 
by pressing back the tissues as traction is being made. (Fig. 417.) 
Having thus brought a loop of each ligament through the wall, 
the loop is secured to the aponeurosis by catgut sutures. Pre- 
vious to securing the protruded loop see that the uterus is in 



DISPLACEMENTS OF THE PELVIC ORGANS. 



541 



proper position. If it is not, the portion of ligament next to the 
uterus can be pulled upon to the necessary degree to accomplish 
the object. The ligaments secured, the wound is closed by a con- 
tinuous chromic catgut suture in the peritoneum and muscle 
edges. This suture should be drawn over firmly enough to hold 
in apposition the peritoneal surfaces and not strangulate the 
muscle structure. A second suture closes the aponeurosis and 
the third the skin surfaces. The greatest care must be exercised 
to prevent the accumulation of blood above or beneath the 
aponeurosis, for such an accumulation is readily infected and the 
formation of an abscess will result in a weakened ventrum — pos- 
sibly in sloughing of the aponeurosis. Bleeding vessels should be 




Fig. 418. — Sutures Introduced for Ventrosuspension. 



ligated, and where there is a tendency to oozing, drainage should 
be employed. This m^ethod of treatment possesses the advan- 
tages that: I, it affords ample opportunity for the recognition 
and treatment of diseased conditions of the pelvic structures; 
2, no opportunity is added by the operation for the formation of 
disturbing pelvic adhesions; 3, the natural condition is more 
closely imitated and the uterus maintained in position by liga- 
ments capable of evolution and involution. 

Ventrofixation and Ventrosuspension. — These terms are ap- 
plied to the operation devised by Olshausen, and modified by 
Kelly, for establishing an artificial ligament for the purpose of 
maintaining the uterus forward. The operation consists in an 



542 , GYNECOLOGY. 

incision in the median line, through which the uterus is exposed 
and its fundus sutured to the parietal peritoneum at the lower 
angle of the wound. Two or three buried sutures of silk, silk- 
worm-gut, catgut, or silver wire are generally employed. (Fig. 
418.) The first suture is passed through the peritoneum about 
one centimeter from the w^ound margin, through the fundus 
uteri near its center, and brought out through the peritoneum 
of the opposite side of the wound. A second suture is similarly 
placed about eight millimeters behind the first. To prevent 
the peritoneum from being dragged away from the abdominal 
wall it is included in the abdominal suture. Since the first 
edition of this book I have modified my method of performing 
this operation by introducing a silkworm-gut suture through 
the fundus of the uterus and the abdominal walls, which is sub- 
sequently tied externally. A needle, carrying a chromic catgut 
suture, is introduced through the aponeurosis of the lower angle 
of the right side, through the fundus of the uterus, near the silk- 
worm-gut suture, and brought out through the peritoneum of the 
opposite side. Two subsequent turns of the suture are passed 
through the edges of the peritoneum and the fundus of the uterus, 
after which the peritoneal wound is closed with the remaining 
suture. Following the introduction of silkworm-gut sutures 
through all the tissues above the peritoneum, this same catgut 
suture is carried back through the aponeurosis and tied at the 
lower angle of the wound. Therefore the uterus, peritoneum, 
and aponeurosis are all held by the one suture, and only a single 
buried knot remains in the incision. Silkworm-gut sutures, in- 
cluding the one through the fundus uteri, are then tied, which 
would bring in apposition and secure the skin edges. The stay 
or lower suture of silk^vorm-gut may be tied over a pledget of 
gauze to prevent it cutting the skin, and should be permitted to 
remain for two weeks. This operation establishes a ligamentous 
band between the uterus and parietal peritoneum, which is suf- 
ficiently strong to maintain the uterus fonvard and yet not inter- 
fere with its mobility. Where it is preferable — as, for instance, 
after the climacteric, or in patients from whom both ovaries 
have been removed — that the uterus should be more firmty 
fixed to the abdominal wall, it is better that the peritoneum 
should be pushed back so that the sutures bring the muscle 
structure directly in contact with the fundus of the uterus. 
Such a course secures a firmer union and, therefore, the uterus 
is held more closely to the parietal wall. The procedure we have 
described permits thorough exploration of the pelvic cavity, 
the separation of adhesions, and the fixation of the uterus 
through a single incision. The procedure has been greatly 
modified. By some, the sutures are placed in the anterior uterine 



DISPLACEAJENTS OF THE PELVIC ORGANS. 543 

wall. The majority of operators insert them in the fundus — 
the first suture in the line of the Fallopian tubes, and the second 
a little behind it, thus throwing the uterus forward in slight 
anteflexion. The purpose of the operation of ventrosuspension 
is to establish a ligamentous union, which will permit a certain 
amount of uterine mobility. Consequently the uterus is attached 
only to the peritoneum, rather than to the muscle wall. To 
avoid the buried suture, F. Martin has suggested using the 
urachus, and Avhen it is not well defined, a loop of peritoneum 
is carried from below upward through a buttonhole slit in the 
fundus and included in the sutures closing the wound. Bovee 
employs a portion of muscle aponeurosis. These modifications, 
however, have no special advantage. The fixation has been 
accomplished through a transverse incision above the symphysis. 
This incision only divides the skin and superficial fascia. A 
vertical incision is then made through the aponeurosis, muscle 
wall, and peritoneum. The uterus is brought forward and se- 
cured by two silkworm-gut sutures through the fundus. These 
are brought out through the muscle wall and segment of integu- 
ment below the transverse incision. The remaining portion of 
the vertical wound is closed with catgut and the transverse in- 
cision in the skin with a continuous intercut icular stitch of silk. 
The suspensory stitches are tied over a gauze roll and permitted 
to remain two weeks. Ventrosuspension has the advantages 
already suggested, that it permits the inspection of the con- 
dition of the peritoneal cavity, the treatment of diseased appen- 
dages, the separation of adhesions, and the fixation forward of 
the uterus in a position which is unlikely to give distress. It has 
the following disadvantages : (i) That it has been found to inter- 
fere to some degree 'with subsequent gestation and labor, the 
patient complaining of more or less pulling and distress during 
the progress of gestation, sometimes so marked as to cause abor- 
tion or premature labor. When the band of fixation is short, large, 
and firm, it may prevent enlargement of the uterus and produce 
thinning of the posterior wall, which will increase the danger 
■of rupture and afford obstacles to the normal progress of par- 
turition. A firm band of adhesion, during pregnancy, after the 
performance of ventrofixation, may cause a condition simulating 
a bifid uterus. I have, in several instances, opened the abdomen 
during pregnancy and cut the band in order to permit the uterus 
properly to develop. Furthermore, I have seen patients in whom 
I felt that such a procedure was advisable. In one instance I 
Avas called in consultation to see a woman who had had a ventro- 
suspension performed and who was in labor at full term. The 
anterior wall of the uterus and cervix were apparently' doubled up, 
forming a shelf upon which the fetus rested with an arm protrud- 



544 GYNECOLOGY. 

ing. The attendants, after vigorous efforts to turn the child, had 
cut off this arm. The fetus was lying in a transverse position,, 
and a part of the body had engaged. After considerable difficulty 
I succeeded in passing a cephalotribe upon the body of the child, 
with which I crushed the spine and delivered first the lower ex- 
tremities, and then the trunk and head. (2) That the operation 
is not free from danger. I had the misfortune to have one 
patient in whom a large portion of intestine slipped below the 
band of adhesion immediately following the operation. This 
became strangulated and caused death. Similar cases have been 
reported by Lindfors, Jacobi, Olshausen, and others. The 
accident in my case occurred almost immediately after the 
operation, and, although the patient suffered greatly, it was 
attributed by her attendants to hysterical excitement following 
the anesthetic, and, when recognized, the condition of the 
patient was such as to preclude any hope of recovery. It would 
not require great stress upon the imagination, when one sees 
these bands of adhesion, to appreciate the possibility of strangu- 
lation occurring at periods more remote from the operation, 
and numbers of such instances are recorded. (3) The buried 
sutures of silla\^orm-gut, silk, or silver wire may become a source 
of irritation, either from immediate infection or later inflamma- 
tory changes, and cause a sinus to extend through the abdominal 
wall and give rise to an unpleasant discharge. Such a sequence, 
of course, annoys both patient and surgeon until the offending 
cause — the buried sutures — have been removed or have become 
disintegrated. Such a sinus may keep up for months or even 
years. The sutures can occasionally be fished up and removed. 
For this purpose I know of no instrument better adapted than 
the hook of the ear-spoon devised by the elder Gross for the 
removal of hardened wax from the ear. If this instrument is 
ineffective, the surgeon may find himself obliged to reopen the 
wound, and frequently the offending ligatiu-e will be found deep 
in the pelvis, at the end of the band of adhesion. For the pur- 
pose of avoiding this difficulty I have employed the chromic 
catgut suture with a single knot. Burrage has advised ventro- 
fixation for the treatment of immobile anteflexion. Through 
an abdominal incision he divides the uterosacral ligaments close 
to the uterus and secures the fundus to the abdominal wall. 
Schmidt, of Cologne, frees the anterior uterine wall from the 
bladder by dissection, excises a wedge-shaped piece with its 
point directed toward the cervical canal, and unites the surfaces 
by sutures. This draws the uterus forward in a position of 
anteflexion. 

Vaginal Operations. — The ease with which the pelvis can 
be entered through the vagina has led to the adoption of various 



DISPLACEMENTS OF THE PELVIC ORGANS. 545 

Operative procedures through this canal for the purpose of 
maintaining the uterus in proper position. One of the earhest 
operations performed through the vagina is that known as the 
Schiicking. This consists in passing an instrument, curved, 
for an acute anteflexion, to the fundus, from which a concealed 
needle is driven through the anterior vaginal fornix. This needle 
carries back the ligature, which, when tied, fixes the uterus in a 
position of anteflexion. Care must be exercised in its employ- 
ment to avoid injuring the bladder by pushing this organ to one 
side. Injury of the intestine has also occurred. The ligature 
is permitted to remain for two or three weeks, when the resiilting 
inflammatory changes will maintain the uterus in an anteflexed 
position. The procedure is objectionable in that it is a blind 
operation, and injury, therefore, may be unavoidable. In- 
struments have been devised to push the uterus against the 
anterior abdominal wall and thrust needles carrying ligatures 
from its cavity, by which the fundus can be fastened ; but these 
are open to the objection already assigned — that they are blind 
procedures. Vaginal fixation devised by Diihrssen, subse- 
quently practised and modified by Mackenrodt, consists in 
making a vertical incision through the anterior vaginal wall to 
the cervix, when the bladder is pushed off until the peritoneum 
is reached. Without opening the latter a suture is introduced, 
and by it the uterus is pulled forward. A second suture, placed 
higher, near the fundus, is employed to maintain the uterus 
forward by bringing its ends through the edges of the vaginal 
incision. Mackenrodt modified the operation by opening through 
the peritoneum and introducing the sutures at a higher level, 
thus securing the fundus or anterior wall to the vaginal incision. 
The peritoneal and vaginal wounds were then closed. This 
operation for a time was very largely practised, but it was soon 
recognized that it was likely to cause much distress and discom- 
fort during the progress of gestation. Moreover, it often pro- 
duced profound dystocia, which imperiled the lives of both 
mother and child. For these reasons the operation is now 
rather infrequently practised. Vineberg and Wertheim, through 
a similar incision, seize the round ligament some three centi- 
meters from the fundus uteri, pass a ligature beneath it, and 
bring the ends of this ligature out through the vaginal walls on 
either side of the vertical incision. The ligature is then tied. 
This holds the round ligament down against the vagina, and, 
consequently, fixes the uterus forward. The round ligaments 
have also been shortened through the vagina by performing 
the Wylie or Mann operation upon them. I have sutured the 
round ligaments to the anterior surface of the uterus through 
the vaginal opening. The operation of Ries consists in pulling 
35 



546 . GYNECOLOGY. 

a loop of the round ligament through a slit in the anterior wall 
of the uterus. This method has been described under abdominal 
procedures, but was devised to be performed through the vaginal 
incision. Through a posterior colpotomy by a vertical incision, 
Freund and Gottschalk shortened the uterosacral ligaments. 
The incision was made from just behind the cervix downward, 
toward the rectum. The peritoneal cavity was opened and a 
ligature introduced on each side to separate the surfaces. From 
this opening a ligature w^as carried through the middle of the 
uterosacral ligament, and one end of it through the posterior 
surface of the cervix. The ligature thus introduced on each side 
was tied, which drew the cervix upward and backward. Con- 
sequently the other end of the lever, the fundus, was thrown 
forward. A modification of this procedure has been extensively 
practised by Bovee, of Washington, who shortens the ligament 
without opening the peritoneum, and is quite an enthusiastic ad- 
vocate of it. Pry or advocated a transverse incision in the pos- 
terior fornix of the vagina, through which he broke up adhesions, 
carried the uterus forward, and packed gauze into the posterior 
culdesac. Then with a tampon he pressed the cervix well up- 
ward and backward. The subsequent adhesion of the cervix in 
this position leads to correction of the malposition. 

512. Lateral Flexion. — Lateral uterine bending may be dex- 
trofiexion or sinistroflexion. The position of the cervix is more 
or less fixed and the fundus of the uterus is drawn to one side 
by cicatricial contraction, or is pushed to the opposite by a large 
exudate, an intraligamentary fibroid growth, or an ovarian cyst. 
No special symptoms characterize the state; the diagnosis is 
readily determined by the methods already cited for the deter- 
mination of other forms of displacement. 

513. Complications Associated with Displacements. — It has 
been noted, in discussing the individual forms of displacement 
of the uterus, that they rarely produce symptoms themselves, 
and, when it is considered that the organ involved, in its normal 
condition, weighs less than an ounce, that its circulation is so 
extrinsic that the organ can be bent forward or backward with- 
out injury thereto, it is difficult to see why so much stress has 
been placed upon these displacements. 

The development of a complication, however, by which the 
circulation is obstructed, changes the whole aspect of affairs. 
The most frequent complications of uterine displacements are: 

Endometritis. 

Metritis. 

Salpingitis. 

Oophoritis. 

Cellulitis. 



] \ DISPLACEMENTS OF THE PELVIC ORGANS. 547 

Peritonitis. ' 

Other complications are : 

Ectopic gestation. 

Ovarian or myomatous tumors. 

Ptosis of the aJDdominal viscera. 

These complications are most frequently primary as regards 
the production of symptoms, though, as in prolapsus, they may 
be secondary in the sense that the displacement lessens the 
resistance to infection. 

514. Prognosis of Displacements. — The prognosis of a dis- 
placement will depend upon its degree and the existence of 
complications. In the earlier stage of the displacement, when 
the distress arises from increased weight of the organ, the mere 
correction of the position and the maintenance of the organ 
corrected will bring about a decrease in its size and afford relief 
from the displacement. After the displacement has existed for 
some time, it is complicated by chronic inflammatory changes, 
which will absolutely prevent any procedure from maintaining 
the organ in its proper position. The symptomatic phenomena, 
however, can be relieved and the patient be practically restored 
to health. 

515. General Treatment. — It will be seen, from a discussion 
of the different forms of displacement, that I am disinclined to 
believe that uncomplicated displacements are likely to produce 
symptoms. Of course, I can readily understand that when a 
patient has prolapsus, with the uterus protruding from the 
body, it necessarily produces disturbance and is subject to 
unusual irritation from its abnormal location. The small size 
of the uterus, when normal, the manner in which it receives and 
discharges its blood-supply, render it difficult to conceive how 
the mere displacement of so movable an organ should be pro- 
vocative of the serious symptoms which have been frequently 
attributed to it. The most 'frequent complications of uterine dis- 
placement are inflammatory processes and their sequelae, which 
cause increase in the size of the organ, its flxation by extensive 
adhesions, and interference with the performance of the function 
of the adjacent viscera. The treatment, then, must largely 
consist in the correction of the existing complication. Expe- 
rience has disclosed, however, that when such complications 
exist, their treatment is most effective when associated with 
measures directed to maintain the uterus in proper position. 
The methods of procedure most effective to accomplish this 
purpose are both local and constitutional, such as massage, 
electricity, and mechanical procedures. The patient should be 
suitably clad, and wear clothing free from undue constrictions 
about the waist. Her skirts should be supported from the 



548 GYNECOLOGY. 

shoulders. The bowels should be carefully regulated, and the 
bladder should not be permitted to become overdistended. The 
existence of peri-uterine inflammation and extensive exudates 
can be ameliorated and absorption expedited by the employ- 
ment of pelvic massage. This is best performed by a daily 
seance of five to ten minutes or more, after the more severe 
distress and pain have been relieved. The vault of the vagina 
may occasionally be painted with tincture of iodin, and in the 
intervals between the massage, tampons, medicated preferably 
with an antiseptic solution containing glycerin, should be worn. 
The tampon maintains the uterus at a higher level, promotes 
the absorption of exudation, facilitates involution, and thus 
favors its maintenance in a normal position. Vaginal douches, 
hot rectal enemas, hot sitz-baths, or the application of heat 
over the abdomen or pelvis in the form of hot sand or a peat 
bath will be found beneficial. Pressure over the abdomen, 
particularly where a mass of exudate is recognized, will promote 
its absorption. This action oftentimes causes such an exudate 
to melt entirely away. The pressure can be effected by the use 
of a shot bag, by which three to five pounds or more of shot are 
retained over the affected surface. When the uterus is freely 
movable or the adhesions have been absorbed, the organ can 
be maintained in its proper position by a suitable pessary. It 
should, however, be recognized that the physician must be able 
to replace the uterus in its proper position before employing this 
instrument. The pessary does not act as a corrective agent, 
but only as a crutch to support and maintain the uterus in its 
corrected position. The pessaries are generally made of soft 
and hard rubber, sometimes of wire coated with soft rubber. 
The soft -rubber instruments absorb the discharges from the 
vagina, decompose, become exceedingly foul, and cause a very 
disagreeable odor. During the time the pessary is worn it is 
important that the vagina should be' daily irrigated. Solutions 
of the inorganic salts should not be employed for irrigation, for 
they are likely to become deposited upon the surface of the 
pessary, cause it to be rough, and thus lead to abrasion and 
ulceration. Care must be exercised in the employment of the 
pessary that it shall not be either unduly large or too small. An 
overlarge instrument makes pressure upon the surfaces of the 
vagina, causes ulceration and the formation of granulations, 
which may envelop a large portion of the pessary and finally 
cause it to become embedded in cicatricial tissue. Too small 
an instrument permits the uterus to fall back over the pessary, 
or the pessary itself to be twisted around and thus prevent it 
being of any service. 

516. Summary. — In anteversion and anteflexion of moderate 



DISPLACEMENTS OF THE PELVIC ORGANS. 549 

degree constitutional measures for the improvement of the 
general health, the regulation of the secretions, enforced rest 
during menstruation, with dilatation, curetment, and the estab- 
lishment of proper drainage will be means sufficient to establish 
a symptomatic ciire. When the anteflexion is acute and dys- 
menorrhea is marked, curetment will generally be of only tem- 
porary benefit and should be followed by splitting the posterior 
lip and suturing the surfaces, as advised by E. C. Dudley. Retro- 
version and retroflexion are capable of producing marked influ- 
ence upon the general health, but should not be considered 
as indicating the practice of special procedures unless they are 
productive of symptoms. The correction and maintenance of 
the uterus in its proper position is indicated as a preliminary' 
treatment of any complication, and retroversion, associated 
with subinvolution following a recent parturition, unless com- 
plicated by perimetritic adhesions, should be considered an 
indication for the use of the pessary, but the previous replace- 
ment of the organ must be a sine qua non. In retroflexion, if 
the pessary is not well borne and the uterus is freely movable, 
the Alexander operation may be employed. The great frequency 
with which inflammation and more or less adhesion of the uterus 
occurs greatly limits the number of cases to which this operation 
is applicable. Indeed, I would prefer to make the median inci- 
sion, for it enables us thoroughly to examine the condition of 
the pelvic viscera, to break up existing adhesions, and to treat 
diseased conditions of the ovaries and tubes. As already seen, 
the great majority of operations for shortening the round liga- 
ments within the abdomen utilize the strongest portion of the 
ligament and leave the weakest undisturbed, with the probability 
of a redevelopment of the condition. The combination of the 
operations of Gilliam and Simpson, which I have employed, seems 
to me the most desirable, as it accomplishes all that the Alexander 
operation could do. Moreover, it has the advantage over the 
operation of ventrosuspension in that it affords no opportunity 
for the formation of adhesions which may serve as a trap by which 
a knuckle of intestine may become fixed and obstructed. My 
experience leads me to the performance of the operation known 
as ventrosuspension or ventrofixation less and less frequently. 
Of the vaginal operations, the ones pursued by Vineberg and 
Bovee are the most serviceable. The other vaginal operations 
have proved unsatisfactory, for many of the patients thus operated 
upon have experienced trouble during subsequent pregnancy. 
Prolapsus uteri is a condition which should receive early con- 
sideration. The longer the displacement is permitted to remain 
unantagonized, the greater are the chances that it can not be com- 
pletely restored. The first stage of uterovaginal prolapse can be 



550 GYNECOLOGY. 

corrected by the employment of a suitable pessary. One should 
be employed Avhich will maintain the uterus in a position of ante- 
flexion or anteversion. The early stage of vagino -uterine prolapse 
should be considered an indication for the prompt retraction of 
the relaxed vaginal walls and the restoration of the perineum. 
The accompanying cystocele should be treated by an excision of 
the redundant vaginal portion of the septum. This surface 
should be sutured in a transverse direction in preference to the su- 
ture that is sometimes advocated, known as the Stolz suture, 
which shortens the vagina in every direction. The importance of 
having a long anterior vaginal segment is seen in its influence in 
maintaining the cervix at a higher level, consequently throwing 
the fundus forward. In the later stages of prolapsus the vaginal 
plastic operation should be supplemented by an abdominal pro- 
cedure to maintain the organ forward. This may be accom- 
plished by shortening of the round ligaments and of the utero- 
sacral. After the climacteric, especially when the uterus shows a 
marked tendency to descent, fixation of the organ is desirable. 
In very extensive prolapsus or in elongation of the supravaginal 
cervix the fundus uteri should be amputated, and the stump can 
then be secured to the upper part of the broad ligament or to the 
anterior abdominal wall. Very frequently the condition will be 
complicated by an extensive hernia through Douglas' pouch, 
when an extensive vaginal plastic operation, combined with a 
ventrofixation, will not necessarily prevent the development of 
this condition. The hernia may be obviated, however, by sutur- 
ing together the fold of Douglas over the rectum and the remain- 
ing part of each fold to the side of the rectum. Enteroptosis may 
be still further prevented by fastening the colon to the abdominal 
parietes. My experience has led me to condemn the Freund 
operation as one of no value. 

517. Inversion of the Uterus. — Inversion of the uterus is 
that condition in w^hich its inner or mucous surface is outside 
and its internal or peritoneal surface within. Inversion can 
be partial or complete, and presents three different degrees: 
In a partial inversion the body of the organ is depressed and 
inverted until it reaches the cervix, but without dilating the 
latter, when it is known as the first degree, or inversion intra- 
uterine. (Fig. 419.) Next, the fundus protrudes through the 
cervix, the cervix being turned down upon the neck like a cuff, 
which is .the second degree, or inversion intravaginal. (Fig. 
420.) In the third degree the entire uterus is inverted, and 
with it, not infrequently, the vagina, the uterus hanging outside 
the vulva, and this is known as inversion extravaginal. (Fig. 
421.) Now, every degree of this form of alteration of the uterus 
can combine itself with a partial or total inversion of the vagina, 



DISPLACEMEXTS OF THE PELVIC ORGANS. 



551 



so the view that the third degree only is necessarily combined 
with prolapsus is a mistake. A trifling degree of inversion or 
partial turning in of the uterus is called invagination. This may 
be a mere depression, over which the mucous surface becomes 
convex, while the peritoneal surface forms a depression or con- 
cavity. As this depression continues, the proximity of the tubes 
and round ligaments to the ligamentum ovarium draws these 
structures into the opening. The ovaries may rest upon the 
funnel-shaped depression, while the tube is necessarily, for a 
part of its extent, drawn into the cavity. The cavity, with its 





Fig. 419. — Partial Inversion of the 
Uterus, Showing: Three Degrees. 



Fig. 420. — Intra vaginal Inversion; 
Three Degrees. 



enlarged opening in the peritoneal cavity, is called the inversion 
funnel. This funnel is usually not quite the depth of the ordinary 
length of the uterine cavity. If the inversion continues for 
some time, secondary phenomena result, from retrogressive 
processes, but the uterus returns to its normal size. The in- 
verted mucous membrane is covered with epithelium; the neck 
of the uterus is small, generally surrounded by a cuff of tissue, 
derived from the cervix, which has not been completely inverted 
— a cervical ring. The longer the inversion exists, the more consid- 
erable is the congestion, with edematous enlargement, and thick- 
ening which form the misproport ion between the narrow inversion 



552 



GYNECOLOGY. 



funnel and the enveloping cnff of the cervix. We not infre- 
quently find diseases of the adnexa. The orifice of the tube 
situated in the vagina can readily be the avenue for the passage 
of infection into the deeper structures. The uterine inner surface 
of the tubal mouths is exposed, the projecting mucous membrane 
is frequently rubbed and irritated, so this door stands open for 




\ 



J.. 




Fig. 421. — Extra vaginal Inversion; 
Three Degrees. 



Fig. 422. — Nonpuerperal Inversion. 
Fibroid Tumor Attached to the 
Fundus Uteri. 



the entrance of germs, and infection can take its way through the 
tubal mucous membrane or by the lymphatics to the deeper 
tissues, producing endosalpingitis, suppurative processes in the 
ovary, or purulent pelvioperitonitis by extension of infection 
from the connective tissue. In ordinary conditions we can have 
involvement of the cellular tissue from such infectious processes. 



DISPLACEMENTS OF THE PELVIC ORGANS. 



553 



Alterations in the peritoneal covering of the inversion funnel 
occur, which render the condition more or less fixed. 

518. Etiology. — Inversion generally arises from two causes: 
first, from puerperal conditions, relaxation, or partial paralysis 
of the uterus during the process of labor, especially the third 
stage of labor; and, second, the nonpuerperal form, in which 
the uterus is displaced by the presence of a fibroid tumor at- 
tached to the fundus. (Fig. 422.) These two conditions are 
very much alike in the clinical form of an inversion, but are 




Fig. 423. — Palpation of an Inversion of the First Degree. 



very different in their manner of development. Puerperal 
inversions are much more frequent than those which arise from 
the presence of growths. They are in the proportion of nine to 
one. Total inversion is rare. How much more frequently the 
partial form occurs is difficult to determine, as not infrequently 
partial inversion resulting from the presence of growths is over- 
looked. Puerperal inversion, in some cases, is produced by 
traction upon the cord in the efforts to deliver the placenta ; by 
faulty pressure over the uterus the fundus may be inverted, and 
in the paralyzed condition may be grasped by the deeper struc- 



554 



GYNECOLOGY. 



tures and the inversion progress until it is completed. A short 
cord is an occasional cause for inversion. The traction is made 
upon the cord at a time when the uterus is relaxed and least resist- 
ant. The traction upon the fundus and the subsequent uterine 
contraction very rapidly complete the displacement. Inversion 
rarely occurs spontaneously. The overdistention of the cervix by 
a large fetus frequently causes such relaxation as will permit in- 




Fig. 424. — Palpation of an Inversion of the Second Degree. 

version to occur readily. It will be a matter of interest to know 
w^hether, in the cases in which inversion has occurred, the placenta 
has been attached near the fundus of the uterus. 

519. Symptoms. — Inversion causes characteristic symptoms. 
The patient generally complains of severe pain, which is con- 
tinuous, sometimes for days; sometimes a pulling sensation is 
felt in the vagina. Immediately following the dislocation a severe 
hemorrhage occurs. This continues in noteworthy strength the 



DISPLACEMENTS OF THE PELVIC ORGANS. 



555 



first day of the puerperium, and does not completely disappear, 
but may continue much longer. Later, it appears intermittent, 
but the suspension of discharge rarely corresponds in its duration 
to the normal intermenstrual interval. During the interval there 
is a profuse mucous discharge from the genitalia. The profuse 
blood discharge may cause the death of the patient from acute 
anemia, or later from septic infection. In some cases sponta- 
neous reinversion may take place in the course of the year. The 
condition may be suspected from these phenomena. 




Fig. 425. — -Appearance of Inversion of the Third Degree. 



520. Diagnosis.— Inversion will be suspected from the severe 
pain, the more or less continuous hemorrhage, and the absence 
of the fundus uteri when the hand is placed upon the abdomen. 
Digital examination discloses a globular mass which fills up the 
vagina and is encircled by a cuff -like ring at its upper part. 
This ring is situated at the external os. (Fig. 424.) Placing 
the hand over the abdomen and making deep pressure, the fundus 



556 



GYNECOLOGY. 



of the uterus is found to be absent from its normal situation, 
and, instead, a funnel-shaped excavation is recognized, which is 
ordinarily sufficient to determine the diagnosis. (Fig. 425.) 
In the chronic condition the uterus resumes its normal size, 
presents a globular or pear-shaped mass in the vagina, sur- 
rounded at its upper part by a distinct cuff or ring, and the sound 
will pass into this the same distance on all sides. Bimanual 
examination discloses above a funnel-shaped depression. This 
depression can be more readily determined by drawing upon the 
fundus of the uterus and introducing the finger into the rectum, 
when it can pass over the neck and directly into this funnel. 






Fig. 426. — a. Inversion of the Uterus, b. Fibroid Polypus, 
pus, with Stenosis of the Cervical Canal. 



c. Fibroid Poly- 



The ovaries and tubes are recognized near it or upon its margin. 
By investigation with the speculum the vaginal tumor is smooth, 
glistening, highly reddened, and sometimes at its lower angles 
the openings of the tubes can be recognized. While a vaginal 
examination may afford a suspicion of the character of the dis- 
order, the diagnosis is incomplete without a bimanual investi- 
gation which involves the rectum and belly cavity. When the 
abdominal walls are very thick and palpation is not readily 
determined, the introduction of a sound or a catheter into the 
bladder and of a finger into the rectum enables us to determine 
definitely the presence or absence of the uterine body. Inver- 



DISPLACEMENTS OF THE PELVIC ORGANS. 



557 



sion of the uterus is sometimes confounded with fibroid polypus 
which has been extruded into the vagina. (Fig. 426.) A fibroid 
polypus may have a broad-based pedicle and the tumor may 
present a shape very similar to that of an inverted uterus. As it 
is covered with rj;iucous membrane, the superficial similarity may 
be marked. Of course, a fibroid tumor will show no orifice of the 
Fallopian tubes, but the latter are not always distinguished. 
Sensation in the fibroid is a little less marked than in the inverted 
uterus, but is not sufiiciently definite to afford a foundation for 
diagnosis. The sound carried around the cuff of the inverted 
uterus passes on all sides an equal distance. With fibroid tumor 
it would pass into the uterine cavity at one side. (Fig. 426, b.) 
Occasionally, however, the cavity of the uterus may be so stenosed 




Fig. 427. — a. Submucous Fibroma, b. Partial Inversion, c. Partial Division- 

of the Uterus. 



that the sound will not enter, and the diagnosis may then be 
uncertain. (Fig. 426, c.) 

If we grasp the mass and draw it down, the finger in the rec- 
tum will disclose, in the one case, the cup-shaped depression of the 
inverted uterus ; and, in the other, the body of the uterus lying 
above the neck of the growth. In a partial inversion, associated 
with fibroid growth, we may not be able definitely to determine 
the condition until we proceed to operation for the removal of 
the mass. (Fig. 427.) 

521. Treatment. — There is a difference in the treatment of 
the two forms of inversion. In the puerperal condition all that 
is necessary is to replace the uterus, when it will remain, while- 



558- GYNECOLOGY. 

in the nonpuerperal form it is necessary to remove the growths 
which have occasioned it. Reinversion is comparatively easy in 
recent cases. Pressure against the fundus with the hand or 




Fig. 428. — Prolapsus Uteri without Inversion. 




Fig. 429. — Inversion of the Uterus — Extra vaginal. 



DISPLACEMENTS OF THE PELVIC ORGANS. 



559 



fingers in the shape of a cone will be frequently sufficient to carry 
the hand directly into the cavity of the uterus and to accomplish 
its complete reinversion. After the puerperal condition be- 
comes chronic we then have to resort to various methods for re- 
placement of the organ. These methods consist in manual 
treatment — instrumental and operative. In the manual treat- 
ment the fingers exercise a veritable taxis on the inverted organ, 
just the same as in hernia, and the tw^o hands are necessary for 
treatment, in which they play an essentially distinct role. The 
left hand over the abdomen maintains the uterus, while the 




Fig. 430. — Central Taxis. 



right replaces the inversion. Courty introduces one or two 
fingers into the rectum and hooks them over the end of the 
uterus, which fixes it more solidly. The other hand is intro- 
duced partly or totally into the vagina. The method of taxis 
is exercised in various directions; thus, it is central, lateral, or 
peripheral. The taxis is called central when the pressure is made 
against the fundus, or median part of the organ (Fig. 430) ; 
lateral, when it is exercised at the level of one or the other uterine 
cornu (Fig. 431) ; and peripheral when the pressure is exerted on 
the refiex parts (Fig. 432). The latter is exemplified when we 



560 



GYNECOLOGY, 



grasp the fundus in the palm of the hand, pass the fingers to the 
fundus of the vagina, and spread it out, stretching the funnel 
while the fundus is pushed against it. If taxis has been tried 
and found inefficient, we can then resort to instrumental reduc- 
tion. A number of instruments for this purpose have been de- 
vised. The air pessary of Gariel is introduced and distended. It 
exerts a hydrostatic or aerostatic pressure against the fundus, and 
pushes it upward, while the vaginal walls, by their traction, pull 
apart the cervix. This soft pressure in some cases may be suffi- 
cient to accomplish the gradual reduction of the organ. The 
pessary can be introduced and the bandage so applied as to 




Fie. 



maintain the pressure against the cervix (Fig. 433). A vaginal 
tampon of iodoform gauze for twenty-four hours is sometimes 
more effective than the pessary. The pressure is sometimes 
employed against the fundus by having an instrument with a 
cup-shaped end, into which the fundus fits, and a spring upon 
its external surface, by which an elastic pressure is induced. 
(Fig. 434.) This procedure is more effective when combined 
with Marcy's suggested insertion of two or more ligatures in the 
cervix, by which traction can be made upon it, while pressure 
is made against the fundus. Thomas advised opening the abdo- 
men and dilating the cervix with an instrument similar to a 



DISPLACEMENTS OF THE PELVIC ORGANS. 



561 





Fig. 432. — Peripheral Taxis. 




Fig- 433- — The Use of the Air Pessary to Reduce an Inversion. 
36 



562 



GYNECOLOGY 



glove-stretcher, while pressure is made against the fundus. 
(Fig. 435.) This procedure was successful in one case and fatal 
in another. It has been suggested to introduce the index-finger 
of one hand into the rectum, and that of the other into the blad- 
der, hooking them into the funnel-shaped depression of the 
uterus, while the thumbs are pressed against the fundus. Kiist- 
ner advocates making a transverse incision through the posterior 
fornix of the vagina into Douglas' culdesac, through which he 
presses the index-finger of the left hand into the inversion funnel, 
and attempts with the thumb of the same hand to press up the 
fundus. If the procedure fails, he advises splitting through the 
posterior uterine wall, in the median line, by a longitudinal in- 
cision, which may extend to within two centimeters of the fundus, 




Fig. 434. — Reduction of Inversion with White's Apparatus. 



from the mucous surface to the peritoneal. (Fig. 436.) The 
renewal of attempts at reinversion under such circumstances is 
usually successful, for the reason that the resistance is removed 
and we are consequently enabled to replace the organ. After 
the uterus has been reinverted the fundus is turned down through 
the vaginal opening and a number of sutures are introduced to 
close the incision. Hirst advises a cut through the vaginal por- 
tion of the cervix only. Cases have been recorded of spontane- 
ous reduction of the inversion when the vulva has been distended 
with the patient in the genupectoral position. If the conditions 



DISPLACEMENTS OF THE PELVIC ORGANS. 



563 



are unfavorable for an operation of reinversion, we can proceed 
to total extirpation of the uterus or to amputation of the inverted 
fundus. When the amputation of the fundus only is made, it is 
very important to guard against reinversion of the stump with a 
resulting hemorrhage into the peritoneal cavity. The stump may 
be secured by three or four partial ligatures, and then the ampu- 
tation may be made below them. When the inversion is pro- 
duced by the presence of tumors, we may content ourselves 




Fig. 435. — Intraperitoneal Dilatation of the Uterus. 



simply with the removal of the gro^^i:hs and the reinversion of 
the organ; or when the organ is very extensively involved, it 
may be necessary to remove the fundus with the growth. The 
possibility of partial inversion should always be kept in mind 
in operating upon partial extrusion of groT\i:hs from the uterine 
cavity. Numerous cases are recorded in which a fibroid polypus 
or growth has been removed by the wire ecraseur, and examina- 
tion subsequently disclosed that a portion of the uterine wall was 



564 



GYNECOLOGY. 



removed, causing an opening into the abdominal cavity. With 
growths projecting into the vagina, the preferable procedure is 
a careful enucleation of the tumor. The tumor is depressed and 
held while the enucleation is performed under the eye, so that, 
even though an inversion has occurred, by hugging the tumor 
closely we prevent breaking through the wall of the uterus. 

522. Displacements of the Appendages. — Displacements of 
the ovaries and tubes are verv common with backward uterine 




Fig. 



436. — Incision of the Posterior Uterine Wall Preliminary to Reduction 
of an Inversion. 



displacement. Inflammatory troubles in the tubes cause them 
to drop down, from increased weight, and they are found behind 
the uterus in Douglas' pouch. (Fig. 43 7 . ) Frequently both tubes 
may be situated in this position, and, united at their abdominal 
ends, form a single tumor, which contains pus or serum. The 
tubes are dislocated by their attachment to growths; ovarian, 



DISPLACEMENTS OF THE PELVIC ORGANS. 



565 



fibroid, or broad-ligament cysts may draw the tube up into the 
abdominal cavity and almost double its length. The most fre- 
quent dislocation of the ovaries is downward, into Douglas' 
culdesac. This prolapse can occur as a consequence of retro- 
displacement, pr, independent of it, from elongation or rupture 
of the infundibulopelvic ligament. The dislocation can be 
occasioned by enlargement of the ovary, or the hypertrophy 
may be secondary to the displacement. The complication of 
retrodisplacement with ovarian prolapse is a source of additional 
distress and annoyance to a patient, as the tender ovarian struc- 
tures are subject to pressure from the heavy uterus and from 
the passage over 
them of the contents 
of the bowel. In 
this situation they 
are also subject to 
pain and distress 
during the act of 
coition, often rend- 
ering it so painful 
that the act is 
dreaded by the pa- 
tient. 

523. Symptoms. 
— Prolapse of the 
ovary is generally 
associated with 
chronic inflamma- 
tion, either as a 
primary or second- 
ary condition. The 
symptoms from 
which the patients 
suffer are necessar- 
ily those which to some degree are occasioned by the chronic 
disorder. In addition to this fact, however, the patient suifers 
distress during fecal evacuation, during the act of coition, in 
walking, and on standing. The ache and distress are some- 
times so severe as to render the patient unable to assume or 
retain the upright position; a condition of semi-invalidism from 
the influence upon the nervous system is engendered similar to 
that present in chronic ovarian inflammation. There are no 
symptoms characteristic of tubal displacement. 

524. Diagnosis. — Prolapse of the ovary, when freely movable, 
is readily determined by bimanual palpation. A mass can be 
felt posterior to the uterus in Douglas' pouch, which varies from 




Fisf. 



437- 



Prolapsus of Ovary and- Tube behind 
Uterus. 



566 GYNECOLOGY. 

the size of an almond to that of a small orange. These masses 
can be pushed up, and, as they rise in the pelvis, fall toward the 
side corresponding to the affected ovary, and drop backward as 
soon as the force is removed. When the ovary is enveloped with 
inflammatory exudate in the pelvis, it is more difficult to deter- 
mine its situation, and, in fact, it may not be discovered until 
after the abdominal cavity is opened. Tubal enlargement with 
adhesions can frequently be mapped out as extending around the 
side of the uterus on its posterior surface, and the organs are 
more or less fixed. 

525. Treatment. — In inflammatory conditions of the tube 
involving the ovaries the treatment is the same as that of the 
diseased condition, as described in Section 468. Prolapse of the 
ovary associated with chronic ovaritis, in which the ovaries are 
very much enlarged, is best treated by extirpation. When 
the enlargement is simply due to prolapse, causing more or 
less ovarian edema, the organ should be brought up and fixed 
in its proper position. Frequently shortening the round liga- 
ments or ventrofixation will bring with it the restoration of 
,the position of the ovaries. W^hen these, however, do not rest 
upon the posterior surface of the broad ligament, but drag 
backward into Douglas' pouch, the infundibulopelvic ligaments 
should be shortened or the external end of the ovary should be 
stitched to the posterior surface of the broad ligament near its 
upper part. Efforts have been made to maintain the ovary in 
its restored position by mechanical means, but in my experience 
they are usually ineffective. The ovary slips behind the pessary, 
though it have a thick bar, becomes pinched, and adds to the 
distress of the patient. Frequently the ovary will be caught 
behind the instrument, and the patient will be unable to move 
for a few minutes, owing to the severe pinching of the inflamed 
organ. 

GENITO-URINARY HEMORRHAGE. 

526. Hemorrhage a Symptom. — The advisability of consid- 
ering hemorrhage under a separate heading or division, when it 
must be recognized that under all circumstances its presence is 
an indication of the existence of disease rather than the actual 
palpable disorder, may be questioned, but my experience has 
caused me to beheve that in the diseases of women the gravity of 
this symptom is not always fully appreciated, and that this 
failure will be better overcome if the subject is given the im- 
portance of a separate consideration. 

527. Site and Varieties. — Hemorrhage may arise from any 
portion of the genito-urinary tract and from the vessels within 



GENITO-URINARY HEMORRHAGE. 567 

the adjacent cellular tissue. It can occur at any age, though 
it takes place but rarely, except from trauma, prior to puberty. 
The significance of hemorrhage is largely dependent upon the age 
at which it makes its appearance. The hemorrhage is called 
open when the blood escapes from the urethra, vagina, or through 
external injuries; concealed, when within the abdominal cavity 
or in the cellular tissue. In the latter, also, it may be denomi- 
nated as circumscribed. A discharge of blood mixed with urine 
is known as hematuria. An excess of bloody discharge syn- 
chronous with the regular menstrual period is named menor- 
rhagia; while bleeding of an irregular character is named metror- 
rhagia; a collection of blood in the cellular tissue is known as a 
hematoma; when in the tissues of the vulva or vagina, it is called 
a vulvovaginal thrombus or hematoma; into the cellular tissue 
about the uterus, an extraperitoneal hematocele; an accumulation 
within the peritoneal cavity, which is encysted or closed in by 
peritoneal adhesions, is described as an intraperitoneal hemato- 
cele; hemorrhage into the structure of the ovary, when small, is 
known as an ovarian apoplexy; and when large, or frequently 
repeated, so the ovarian stroma is practically destroyed, and ^ 
the collection forms a blood cyst, it is called an ovarian hema-' 
toma. A collection of blood in one of the hollow organs is known, 
in the Fallopian tube, as a hematosalpinx; in the uterus, as a 
hematometra; and in the vagina, as a hematocolpos ; or when the 
collection is so large as to involve all, it is denominated a hemato- 
colpometro salpinx. Further distinctions are retro-uterine, circum- 
uterine, and ante-uterine hematocele, according to the situation 
of the blood collection — ^behind, about, or in front of the uterus. 

528. Hematuria and Its Causes. — Hematuria is blood mixed 
with the urine, and is engendered by urethral caruncle, polypi, 
vegetations, fissures (the latter situated about the internal 
meatus) , and malignant disease of the canal. It occurs in acute 
and chronic cystitis, associated with more or less vesical ulcera- 
tion; in the aggravation of the disorder occasioned by the pres- 
ence of vesical calculi; and malignant growths or villous pro- 
jections from the vesical mucous membrane are a prolific source 
for the occurrence of blood in the urine. It is often produced by 
injury, inflammation, or malignant disease of the ureters or 
kidneys. Stone in the pelvis of the kidney frequently causes 
bloody urine. Occasionally, blood appears in the urine as a 
result of constitutional conditions. So frequently is it associated 
with malarial infection as to give rise to the term ■ malarial 
hematuria. 

529. Symptoms and Diagnosis. — The blood may be mixed 
with the urine, giving it a dark, smoky, often almost black 
appearance, or may precede or follow the act of micturition, as a 



568 GYNECOLOGY. 

few drops of free blood mixed with the urine or in the form of a 
small clot. The clots may be bright and recent, or darkened by 
longer retention within the urine. Unmixed blood comes from 
injury or disease of the urethra; frequently a few drops or a 
small clot will follow urination when caused by a fissure of the 
meatus. When the bleeding is occasioned by disease or injury 
of the bladder, the urine is not constantly bloody. An evacua- 
tion may be perfectly clear and the next be bloody. 

The cause of the symptom is ascertained by careful exami- 
nation. Disorders of the urethral orifice are recognized by in- 
spection of the canal, by palpation, and, if necessary, by inspec- 
tion through an endoscope or a urethral speculum. A fissure 
at the internal urethral orifice causes severe pain upon palpation 
of the urethra. 

Inflammation of the bladder — cystitis — is recognized by pain- 
ful and frequent micturition and attacks of profuse bleeding. 
The microscope reveals the cellular elements of the blood and 
degenerating epithelium in the urine. In growths or foreign 
bodies palpation discloses thickened walls, increased tenderness, 
and possibly the mobility of a foreign body or calculus. Micro- 
scopic investigation of the fluid evacuated is of great value. 
Not infrequently the bladder may be the seat of profuse bleeding, 
which becomes coagulated, and the clots interfere with the col- 
lection and evacuation of the urine. 

Disease of the ureter and pelvis of the kidney may produce 
bloody discharge. Irrigation of the bladder permits the char- 
acter of the urine from the kidney to be determined. Through 
the speculum the ureteric orifice will often be seen as a pouty, 
more or less abraded elevation, from which bloody urine is seen 
to issue. Catheterization of the ureter will determine the char- 
acter of the secretion in the respective kidneys and the existence 
of disease in one or both of the organs. Calculi in the renal 
pelvis are generally a source of pain in the region of the kidney. 
The pain is generally felt along the course of the ureter, not in- 
frequently over the distribution of the genitocrural nerve. 

530. Treatment. — The treatment of hemorrhage is the same 
as that of the condition producing it. Hemorrhage from the 
bladder and urethra must be recognized as of importance. 
Measures for its relief (Section 409) have been described. 

When trouble can not be discovered in the urethra and blad- 
der, the treatment should be directed to the disease in the pelvis 
of the kidney. Before proceeding to internal measures, constitu- 
tional conditions should be excluded. If necessary, the blood 
should be examined for the presence of the malarial plasmodium. 
The determinaiton of malaria should indicate the use of anti- 
malarial remedies. Bleeding may be arrested by the employ- 



GEXITO-URIXARY HEMORRHAGE. 569 

merit of astringents — tannic and gallic acids, hydrastis, and 
hamamelis ; cotarnin hydrochlorate, gr. ss-j ever^^ three hours ; 
ergotin, gr. j-ij four times daily; ol. erigeron, gtt. v-xx every 
three hours ; gelatin in lo per cent, jelly by the stomach, or 
2 to 3 per cent, solution in salt solution by hypodermoctysis. 
Tyson advises ferri persulph., gr. J-^, as very effective. 

Continuation of bleeding associated with renal calculus should 
indicate operation for its removal. Operation will be a conserva- 
tive course, for the continuance of the disorder necessarily results 
in renal degeneration and destruction. 

531. Genital Hemorrhage or Bleeding. — This term is em- 
ployed to distinguish bleeding which makes its exit externally, 
and miay arise from any portion of the genital tract. Bleeding 
of slight character, — a few drops, — which will occasionally soil 
the clothing, will be a source of great anxiety to a nervous patient 
and should be considered an indication for a careful investiga- 
tion by her physician. Such bleeding may arise from irritation 
of the vulva, warty growths, scratching induced by pruritus, 
from caruncle of the urethra, papillary growths and granulations 
of the vestibule or vaginal mucous membrane, lacerations, abra- 
sions or erosions, or beginning malignant diseases of the vagina 
or cervix, inflammation of the endometrium, or changes incident 
to gestation or parturition. ]\Iore severe bleeding or hemorrhage 
is induced by injuries of the vulva caused by falling and striking 
against a sharp object or by kicks or bloAvs ; these injuries cause 
very severe hemorrhage when the bulb of the vestibule is in- 
jured. Hemorrhage, is also incident to malignant disease of the 
labia or clitoris, severe injuries of the vagina, or extensive lacera- 
tions of the cervix. Interstitial endometritis, fibroid groT^1:hs 
encroaching upon the uterine cavity, and epithelioma, carci- 
noma, and sarcoma of the uterus are frequent causes. Hemor- 
rhage from the genital tract may also result from disease outside 
of the canal which interferes with its circulation, as, inflamma- 
tory exudate, cellulitis compressing the vessels of the pelvis and 
interfering with the return circulation, displacements, extra- 
uterine pregnancy, intraligamentary tumors of the ovary or of 
the uterus, inflammation of the Fallopian tubes, chronic inflam- 
mation of the ovaries, and constitutional conditions (as disease 
of the heart, of the kidneys, or of the liver) which affect the 
circulation in the uterus. The circulation is very often tem- 
porarily influenced by the development of zymotic diseases. 
Severe uterine hemorrhage may occasionally usher in an attack 
of typhoid fever. Disturbance of the process of gestation by 
hemorrhage may indicate the occurrence of abortion or of pre- 
mature labor, or may follow abortion or labor where the secun- 
dines or portions of the placenta are retained. 



570 GYNECOLOGY. 

532. Diagnosis. — The determination of the existence of ex- 
ternal hemorrhage, of course, presents no difficulty. It is exceed- 
ingly important, however, that we should be able to recognize its 
etiology and source. This will often be found a difficult ques- 
tion. No physician does justice to his patient who permits her 
to bleed without subjecting her to a careful examination in 
order to ascertain the cause. Not infrequently patients will 
object to the necessary examination. Such a patient should be 
plainly given to understand that the physician can not continue 
to treat her unless she affords him an opportunity to know the 
existing conditions. He will do himself less injury by absolutely 
refusing to treat the case than he will if he yields to the patient's 
objection and endeavors to palliate an unrecognized disease. 
Unfortunately, many patients have an idea that hemorrhage 
at or near the climacteric is a condition to be expected, so if free 
bleeding occurs at this period, they attribute it to the coming 
change of life and continue to endure it. Members of the medical 
profession, I find, are often responsible for this misconception, 
for frequently they advise the patient that the bleeding is inci- 
dent to her period of life, and that, therefore, when this has 
passed over, the hemorrhage will cease. Such a statement, 
however, only calms the patient and favors a transition from the 
existing to another and perhaps more serious state. Moreover, 
when the discovery of the actual condition is made, the time for 
radical measures has elapsed. The occurrence of hemorrhage 
incident to local or constitutional conditions makes it incumbent 
upon us to examine carefully every organ of the body to be 
certain of its cause. In every woman who suffers from hemor- 
rhage, where we are able to eliminate constitutional conditions, 
and where we can discover no disorders in the tissues about the 
organ or any disease of the cervix to explain the cause, the 
uterine cavity should be thoroughly explored. The previous 
history of the patient will enable us to ascertain whether the 
bleeding is due to the retention of products of a recent gestation. 
Bimanual examination will generally reveal even small growths. 
Such a condition will be manifested by localized areas of enlarge- 
ment or resistance in the organ. Some of these growths, being 
pedunculated, can be moved about in the uterine cavity to a 
limited degree. Combined palpation also affords information 
as to the possibility of malignant disease. The latter occurs 
more frequently in the cervix, and when it exists in the body, it 
causes more or less hardening and sense of resistance from the 
presence of infiltration. This, of course, depends somewhat 
upon the associated reactionary inflammation. If the disease 
involves only a portion of the lining membrane of the uterus 
without the infiltration extending into the wall, the bimanual 



GENITO-URINARY HEMORRHAGE. 571 

examination will not reveal the induration. Therefore it will 
be necessary to explore the uterine cavity, preferably with the 
finger. The finger within the uterus and the hand over the 
abdomen enables one to outline and definitely determine the 
thickness and rigidity of the wall and the extent of induration 
as well as the general condition of the uterine mucous membrane. 
In the nonpuerperal uterus, however, one can not readily em- 
ploy digital exploration of its cavity without a previous dilata- 
tion. Dilatation may be accomplished by a variety of methods, 
one of which is the employment of mechanical dilators or of 
graduated bougies. This procedure affords an excellent oppor- 
tunity for the employment of therapeutic measures within the 
uterus, but sufficient dilatation of the organ can not thus be 
secured to allow the introduction of the finger without tearing 
and inflicting serious injury to the structure of the cervix. The 
cervix may be split on either side of the internal os with scissors 
or knife, after which the canal can be dilated or stretched enough 
to permit the introduction of the finger. Often this method of 
procedure is associated with an extensive laceration of the uterine 
structure, and, furthermore, incision of the cervix is too radical 
an operation for mere exploration. It is only when it is neces- 
sary to institute treatment for a threatening condition within the 
uterine cavity that we would advise cervical incision. Another 
method of dilatation is that devised by Vulliet, which consists 
in packing the uterine cavity with pieces of gauze until the cervix 
becomes gradually dilated, and renewing this gauze packing 
until the uterine cavity is so well dilated that the finger can be 
readily introduced. This plan is open to the objections, how- 
ever, that the gauze is an irritant, requires care that the patient 
does not become infected during the progress of the procedure, 
and in many cases, particularly when the cervix is the seat of 
infiammation and is a little rigid, the dilatation is ineffectually 
accomplished. 

The most effective method of dilating the cervix is accom- 
plished by the use of tents. The tents may consist of sponge, 
laminaria, or tupelo. Sponge tents are objectionable on account 
of the difficulty of rendering them sterile and because of the fact 
that they readily become impregnated with the discharges, 
which quickly decompose and predispose to infection. This 
danger has in some degree been obviated by the suggestion that 
the tent be covered with a rubber sleeve, but this requires the 
employment of special measures to convey the moisture to the 
tent. The laminaria tents are exceedingly eff'ective, preferably 
those which are perforated. The tent should be carried into 
the uterine cavity without much force, the tent and the canal 
having been previously rendered, as far as possible, sterile. As 



I 



572 GYNECOLOGY. 

large a tent as can be introduced should be employed. When 
the cavity is somewhat dilated or when the first tent is not 
sufficiently large, and we wish for more complete dilatation, a 
number of tents or a nest can be employed. More rapid dilata- 
tion is accomplished by previously moderately stretching the 
canal with bougies. If aseptic precautions are observed, the 
danger is not thereby increased. The details of the procedure 
and the precautions to be exercised have been given. (Section 

85.) 

533. Treatment. — The treatment should be directed to the 
disorder which has caused the hemorrhage. We may not, how- 
ever, be ready, or the patient can not be subjected to radical 
treatment, while the hemorrhage is so severe as to necessitate the 
exercise of measures to save her life. Various remedies are 
advocated for relief of hemorrhage — agents which exercise con- 
tractile power upon the involuntary uterine mucous membrane, 
of which ergot is one of the most efficient. It not only causes 
contraction of the uterine muscle wall, but also decreases the 
amount of blood that is sent into the uterus through the con- 
traction of the uterine vessels. Thyroid extract and the extract 
of mammary gland have been highly extolled. The various 
astringents are of benefit, as gallic and tannic acids; dilute sul- 
phuric acid; iron salts, especially the persulphate of iron; ham- 
amelis; hydrastis and its salts, hydrastin and hydrastinin; and 
the tincture of cinnamon. The latter may be given with good 
effect in combination with either gallic or tannic acid, giving 
from ten to thirty grains of the acid with a tablespoonful of the 
liquid. Cotarnin hydrochlorate (stypticin), gr. ss-j every two 
or three hours, is frequently very effective in controlling hemor- 
rhage. The patient should be kept perfectly quiet in bed; if 
hemorrhage is severe, she should be prevented from rising even 
to evacuate the bowels or to void the urine. Cold applications 
may be made to the abdomen, and heat or a mustard-plaster ap- 
plied between the shoulders, in order to divert the current of blood 
from the pelvis. Local applications of various astringents, such 
as alum, zinc sulphate, hydrastis, or hamamelis, used in strong 
solution or as a douche, may be employed. Douches of hot 
water should be given the patient while in the recumbent posi- 
tion, using water at from 110° to 115° P., even 120° F. if the 
patient can bear it. Applications to the uterine canal by in- 
jecting a few drops of perchlorid of iron may be employed, or the 
cavity may be swabbed with it. The objection to the injection 
is that the uterine cavity will contract upon its contents, causing 
contraction of the cervix, by which the contents are forced from 
the uterine cavity into the tubes, and produce inflammation 
within them, or, worse, a localized peritonitis. Gersterberg 



GENITO-URINARY HEMORRHAGE. 573 

employs a strong solution of formol upon a cotton-wrapped 
applicator. A solution of aluminium acetate has been advo- 
cated. When hemorrhage is severe, endangering the patient 
by its continuance, the uterine cavity should be tamponed, by 
packing a good-sized piece of gauze firmly into its cavity. This 
prevents the further discharge of blood and facilitates the dilata- 
tion of the canal until it can be explored. These measures for 
the treatment of hemorrhage are merely palliative. They do 
not correct the fault or the trouble which induced it; and the 
earlier radical treatment can be instituted, the better it is for 
the patient and the more readily is the condition controlled. 
Slight bleeding from the vulva and vagina is readily controlled 
by making applications of an astringent or a styptic, such as 
persulphate of iron, directly to the diseased surface. The cavity 
should be packed, in order to secure further improvement through 
pressure. When bleeding occurs from an injury to the vulva, 
the most efficient means is to enlarge the external injury and to 
secure the bleeding vessel by ligation. When a large surface 
bleeds, the hemorrhage is best controlled by packing with iodo- 
form gauze, making firm pressure upon or into the wound. 
When the bleeding is the result of incomplete abortion or the ex- 
istence of an intra-uterine growth, the offending cause should be 
removed. An interstitial endometritis should indicate the em- 
ployment of the curet. Atmocausis, or the application of steam 
to the uterine cavity by a special apparatus, has had many ad- 
vocates, but it would seem desirable to employ more controllable 
measures, for it is impossible accurately to regulate the amount 
of destruction to which the uterine mucosa will be subjected, and 
definitely to equalize its distribution. 

534. Vulvar Hematoma or Hematocele. — ^Vulvar hematoma 
or thrombus is a term applied to hemorrhage which takes place 
into the tissues of the vulva. It arises as a result of injury 
sufficient to cause rupture of a vessel without a break in the in- 
tegument. AVhen the injury involves the bulb of the vestibule, 
the hemorrhage may be extensive and cause a large-sized tumor, 
which involves one or the other large labium. It also occurs 
from rupture of varicose veins or from compression of vessels 
during the progress of labor. The latter is the most frequent 
cause. The tumor may attain the size of an orange or even of 
the fist, and may be very tense and painful. It usually occurs 
suddenly, and is associated with more or less burning and pain in 
the region of the swelling while it develops. When the skin is 
unbroken and the collection does not become infected, it may be 
completely absorbed. 

535. Vaginal Hematoma or Thrombus. — This condition, un- 
complicated, is of rare occurrence. It is usually associated with 



574 GYNECOLOGY. 

hemorrhage into the vulvar tissue, forming a vulvovaginal 
thrombus. It usually occurs upon one side of the vagina, and 
is most frequently a result of injuries sustained during labor. 
The exciting agent is the passage of the presenting part of the 
child, which frequently pulls off and stretches the vaginal at- 
tachments. This causes rupture of the vessels and severe 
bleeding. The tumor may attain a very large size, compress 
the vagina and rectum, and cause difficulty in micturition. The 
physician may be in doubt, when called to see such a patient, 
whether it is an accumulation of blood or a suppurative process. 
The better plan of procedure is, of course, to make a careful 
examination. With the history of the patient in mind, we may 
be able to eliminate the probability of it being inflammatory, 
especially when it occurs shortly after a confinement. During 
the year 1898 I saw a patient, thirty-four years of age, three 
weeks after her first confinement, who had passed through a 
normal labor. She had, however, sustained a slight laceration 
of the perineum, which was repaired. Two weeks subsequent 
to her delivery she developed some elevation of temperature, 
with more or less distress in the pelvis, and examination dis- 
closed a large swelling which compressed the vagina and rectum. 
The mass thus formed was quite large; the right buttock was 
edematous and the mass protruded into the vagina to such a 
degree as greatly to obstruct it, as well as to encroach upon the 
rectum. Sensation of fluctuation was indistinct. The right 
buttock was so much more prominent than the left and the sen- 
sation of elasticity, almost fluctuation, so marked "that I decided 
to incise through it and thus reach the mass, rather than to make 
an incision from the vagina. The incision into the buttock, 
however, disclosed that the swelling in it was entirely edematous. 
Through this incision the levator ani muscle was opened, when 
there was at once a discharge of a large quantity of bloody fluid 
and clots. By pressure through the vagina the mass was readily 
removed, and the patient looked and expressed herself as feeling 
greatly improved. A gauze wick was passed through the wound 
into this cavity with a view to insure drainage and to prevent 
its premature closing. The gauze was removed at the end of 
twenty-four hours, and the subsequent progress of the patient 
was uninterrupted. Another case of this kind came under my 
observation in a young woman who had been delivered by 
forceps. The right side of the pelvis was apparently occupied 
by a large clot, which bulged into the vagina, protruded into 
the labium, and gave rise to suggillation of the entire buttock. 
This mass was incised from the vagina and it was found to extend 
up into the broad ligament of the right side. The clot was 
thoroughly turned out and the cavity packed with a large quan- 



GENITO-URINARY HEMORRHAGE. 575 

tity of iodoform gauze. The patient recovered. I have ob- 
served one case of vaginal hematocele in which labor was com- 
plicated by an ovarian dermoid. The union of this growth with 
the uterus had been destroyed by previous torsion. The tumor 
subsequently became engrafted upon the omentum, from which, 
by a broad band of adhesion, it evidently received its nutrition. 
It was attached below by folds of the peritoneum, which ex- 
tended over and to the left of the bladder. In the latter fold, 
dipping down into the pelvis in front of the bladder and vagina 
and to the left of the latter, was an extensive collection of clotted 
blood, which had evidently been produced by pressure upon 
the inferior attachments of the tumor during the progress of 
labor. 

536. Diagnosis. — Vulvar hematoma is likely to be confounded 
with edema of the labium and with labial tumors. Its devel- 
opment, however, is too sudden for the latter condition. Edema 
of the labium is generally associated with other disorders. It is 
not one-sided. Both labia are involved unless the edema is due 
to some special cause, in which there is obstruction of vessels 
or lymphatics on one side only. Vulvar and vaginal thrombi 
are usually associated, producing the condition already de- 
scribed as vulvovaginal thrombus. The condition generally 
follows difficult or complicated labors. Pus-collections are 
rarely found in the lateral walls of the vagina, but are most fre- 
quently pushed into the vagina from the posterior fornix. 
Thrombi, on the other hand, are frequently found upon the 
lateral surface and rarely affect the posterior vaginal wall. 

537. Treatment. — The amount of bleeding in these thrombi 
is usually limited, for the pressure of the tissues into which bleed- 
ing occurs naturally controls it. In noninfected cases the 
extra vasated mass is ultimately absorbed, although in large 
collections it may remain for quite a long time. A patient 
recently came under my observation in whom an operation 
was required for pelvic inflammation. On examination, a 
mass was felt posterior to the rectum, in the neighborhood of 
the sacrococcygeal articulation, which had an elastic sensation. 
Upon inquiry, I found she had undergone her first labor six 
months before, with a history of an injury to the coccyx. The 
coccygeal injury had, however, disappeared ; the mass remained. 
As I had already made an incision through the vagina into the 
peritoneal cavity, I did not care, therefore, to attempt to open 
into this from the vagina, on account of the dissection required 
around the rectum. An incision was made into this sac pos- 
terior to the anus, when a teacupful of thick, pasty, reddish 
material, evidently the remnants of the clot, was evacuated. 
Gauze drainage was instituted, and the cavity gradually closed. 



576 GYNECOLOGY. 

When the collection is small, it may, without detriment to 
the patient, be left to nature; but when large, the pressure 
produces thinning of the enveloping wall and permits the ready 
introduction of infecting germs, either from the rectum or 
the vagina. In such collections the danger of subsequent 
infection is decreased by free incision and the evacuation of 
the accumulation. Not only should the clots be removed, 
but measures must be employed to preclude further hemorrhage. 
A large bleeding vessel may be sectired by passing a ligature 
beneath or about it with a needle. When ligation is impractic- 
able, hemorrhage should be controlled by packing with iodoform 
gauze. The gauze should be retained for two or three days, 
and should be renewed with a smaller amount, in order to keep 
the external wound open long enough for the cavity to undergo 
thorough contraction. 

538. Peri-uterine hemorrhage may be intraperitoneal or 
extraperitoneal. Intraperitoneal hemorrhage, unless preceded 
by inflammatory adhesions which form limitations, is free, and 
may be large in quantity. Extraperitoneal hemorrhage takes 
place into the cellular tissue about the uterus and the broad 
ligaments, and is limited by the pressure of the tissue. Hemor- 
rhage into the cellular tissue beneath the peritoneum under- 
goes coagulation and forms a bloody tumor, known as a hemato- 
cele. It is analogous to the thrombus which occurs during 
the progress of labor, and which we have described under the 
term vulvovaginal. 

Hemorrhage into the peritoneal cavity will form a coagulum, 
and subsequently a tumor, or, when very free, may remain 
liquid and the hemorrhage continue until the death of the 
patient or until surgical intervention is practised. 

539. Causes. — The causes may be divided into two classes: 
first, hemorrhage that results from extra-uterine pregnancy, 
which is more important, because more frequent and more 
serious in its results; second, hemorrhage of nonpuerperal 
origin, which occurs without the existence of fecundation. 
The pelvis being the most dependent portion of the abdomen, 
hemorrhage from any of the intra-abdominal viscera, or within 
any portion of the peritoneal cavity, naturally gravitates into 
the pelvis. Thus, we may have intra-abdominal hemorrhage 
from traumatic injuries of the liver or spleen, rupture of an 
aneurysm of the aorta or of the celiac axis, rupture of varicose 
veins, from the ovary, regurgitation from the Fallopian tube of 
menstrual blood (particularly when there is obstruction of the 
uterine neck), rupture of a uterine or tubal collection, rupture 
of bands of adhesion in the pelvic peritoneum, slipping of a 
ligature, or the retraction of a cut vessel following an opera- 



GENITO-URINARY HEMORRHAGE. 



577 



tion. Any of these causes may lead to an accumulation of 
blood in the pelvis or, particularly, in Douglas' pouch, whereby 
the intestines containing gas are floated up and the uterus is 
pushed forward. Soon or later the coagulated blood causes 
irritation and l^ads to the formation of adhesions, by which 
the collection may become encysted and form what is known 
as an intraperitoneal hematocele. (Fig. 438.) The most fre- 
quent cause, however, belongs to the division of the puerperal 
or extra-uterine. 

540. Symptoms. — Intra-abdominal hemorrhage from what- 
ever site or cause, unless limited by previous adhesions, will 
gravitate into the pelvis. The gravity of the symptoms will de- 




438. — Intraperitoneal Hemorrhage. 



pend upon the size of the vessels injured and the rapidity of the 
hemorrhage. The rupture of the vessel is generally associated 
with pain in the vicinity of the lesion. This sensation may be 
intense cutting or burning. If the hemorrhage is slight, it 
ma}^ be slow and produce little if any constitutional evidence. 
When severe, the symptoms of shock are profound and may be 
announced by severe, agonizing pain, accompanied by syncope 
or repeated attacks of fainting. The skin is pale, covered with 
a cold, clammy perspiration, the pupils are widely dilated, pulse 
feeble, frequent, or absent in the radius. The mere effort to raise 
the head may lead to unconsciousness. The temperature is sub- 
normal. The syncope may be associated with such reduced 
37 



578 



GYNECOLOGY. 



arterial tension that a clot is formed, which obstructs the bleed- 
ing vessel and becomes so firmly fixed that as the patient reacts 
the hemorrhage is controlled. The salts of the blood so irritate 
the peritoneum that a mild grade of peritonitis results, which 
leads to the collection becoming encysted. The watery portions 
of the blood are absorbed and the clot may gradually become 
organized and result in thickening of the peritoneum and ad- 
hesions as the only traces of its occurrence. More frequently 
the condition from which it has originated, or the stagnation from 
the imprisoned intestinal coils, leads to infection and the for- 
mation or a pelvic 
abscess. Unless 
such a condition is 

i r- M" ' ^ '^'^ // ^..^Sii^^ik^-^ promptly evacu- 

/ ^^AP^ ■ ^ ' M ated, general infec- 

/^^ AyL:^^^-\^' JJ^^HP^Sf' ^^^^ may follow. 

// //'^ "^ y^^fe^>*^BF / ' // 541. Extra p e r i- 

toneal Hematocele. 
— Extraper i t o n e a 1 
hemorrhage result- 
ing in the formation 
of a hematocele may 
be produced by 
puerperal or non- 
puerperal causes. 
(Fig. 439-) .The 
former, associated 
with ectopic gesta- 
tion, are the more 
frequent. The non- 
puerperal causes are 
the rupture into the 
broad hgament of 
varicose veins, and 
injury of an artery or its retraction from the stump when the 
pedicle is ligated en masse. 

542. Symptoms. — Extraperitoneal hematocele in. the broad 
ligament is limited in its character, and causes symptoms similar 
to those which have already been enumerated for the intra- 
peritoneal variety, though in a much slighter degree. The 
indications of shock and collapse are much less marked, and 
hemorrhage, from its limitation, is much less serious in its 
influence. As it occupies the broad ligament, it is usually 
situated upon one side of the pelvis, and pushes the uterus 
to the opposite side. This hemorrhage may be situated either 
in the upper part or in the base of the broad ligament, and 




Fig. 439. — Extraperitoneal Hematoma. 



GEXITO-URIXARY HEMORRHAGE. 579 

may produce different physical signs according to its situation. 
The hemorrhage, when low in the broad ligament, may dis- 
sect forward between the uterus and bladder, or backward 
around the uterus beneath the peritoneum, and extend to 
the opposite side. In the great majority of cases, however, 
extraperitoneal hemorrhage is one-sided. 

543. Diagnosis. — Peri -uterine hemorrhage, w^hether intra- 
peritoneal or extraperitoneal, is determined by the phenom- 
ena of internal hemorrhage. It is true that similar symp- 
toms — a sharp pain, symptoms of collapse — might arise from 
rupture of a pyosalpinx or a pelvic abscess. In such accidents, 
however, acute agonizing pain is caused, with symptoms of 
peritoneal reaction which are more intense than when from 
the hematocele, but a tumor does not form. A retrofiexed 
gravid uterus may be mistaken for hematocele, but the out- 
line of the boundaries of the organ are more definite than those 
found in hematocele. In the latter the uterus is frequently 
inclosed within a mass or pushed forward, while by a careful 
examination in a retrofiexed gravid uterus the cervix is found 
at a higher level, either in the axis of the vagina or looking for- 
ward ; a distinct angle exists between it and the smooth, definitely 
outlined mass filling up the pelvis, which should not be confounded 
with hematocele. Ovarian cysts and uterine fibroids imprisoned 
within the pelvis possess nothing in common with hematocele. 
The manner of appearance and the course of development of 
the condition are entirely dift'erent. Extra-uterine pregnancy 
before rupture does not present similar symptoms, although it 
may be a starting-point for the later hemorrhage, and unless 
the examination is carefully performed, rupture may result from 
the methods used for diagnosis. Extraperitoneal hemorrhage is 
determined from intraperitoneal by the situation of the collec- 
tion upon one side, which is more definitely localized,, its boun- 
daries more sharply defined, and the uterus generally pushed to 
the opposite side, while in the intraperitoneal hematocele the lat- 
ter is surrounded by the accumulation or is pushed forward. 
The determination of the cause of the hemorrhage is not always 
easily accomplished. Previous symptoms of pregnancy, amenor- 
rhea, with symptoms rapidly ushered in, profound depression, 
and very marked anemia, should lead to the suspicion of probable 
rupture of a fetal sac. Symptoms of collapse or depression, of 
internal hemorrhage, may arise from rupture of internal varicose 
veins. In hemorrhagic salpingitis the condition is more insidi- 
ous, the progress more slight, owing to the gradual effusion of 
blood. Should there be any doubt of intraperitoneal hemor- 
rhage, the true condition can be surely determined by making 



580. GYNECOLOGY. 

an exploratory puncture through the posterior vaginal fornix. 
This is a justifiable and commendable procedure. 

544. Prognosis. — The affection is always a serious one. 
We can not be certain that death may not suddenly result 
from a continuation of the hemorrhage, or, when hemorrhage 
has apparently been arrested, that the clot may not be loosened 
and hemorrhage again recur. In large collections the progress 
of the, case is exceedingly tedious. Plastic material remains 
about the uterus for a long time, becomes more or less organized, 
is frequently a source of discomfort, and often a cause of sterility. 
That sterility is not invariably caused is evident from the numer- 
ous cases recorded in which women have suffered from hemato- 
cele, in whom the collection is ultimately absorbed, and the 
patient again undergoes an ectopic gestation, and the experience 
is repeated. The presence of a large collection of blood within 
the pelvis is a source of continuous danger, from its close prox- 
imity to the vagina and rectum, through either of which chan- 
nels infectious material may enter, to cause pelvic suppuration. 
Suppuration is particularly likely to occur if the individual has 
had previous tubal disease, from which, doubtless, the infection 
develops. The extraperitoneal variety is less serious in its in- 
fluence, much more likel}^ to undergo absorption, and leaves 
less evidence of its previous existence. Its situation renders 
it less susceptible to infective changes. When the collection 
is large, however, and has existed for some time, the patient 
will, without question, have a more favorable prognosis by 
the exercise of measures for its removal. 

545. Treatment. — -Active interference must depend very much 
upon the character of the symptoms and the severity of the 
attack. When the symptoms are such as to indicate escape 
of a large quantity of blood into the pelvis, the abdomen should 
be opened promptly, clots removed, and the bleeding vessel 
secured. In profuse internal hemorrhage ligation of the bleed- 
ing vessel is just as certainly indicated as in hemorrhage from 
the radial or femoral artery. When hemorrhage has apparently 
been arrested and a reactive peritonitis develops, we are not 
absolutely certain that the clot can not be displaced and the 
patient suffer from a recurrence of hemorrhage, which may 
be fatal, or that the collection of fluid about which nature is 
forming its barriers may not become infected from the neigh- 
boring hollow viscera and cause subsequent changes, necessitat- 
ing its evacuation, with increased danger to the patient. In 
extraperitoneal hemorrhage the indications for operation are 
not so marked. The symptoms are much slighter, the amount 
of exudation is less, and the probabilities of infection are dimin- 
ished. In such cases we can afford to wait and trust to nature 



GENITO-URINARY HEMORRHAGE. 581 

to absorb the effused fluid. In large collection^, however, 
much time will be saved by its evacuation. The method of 
operative procedure will depend upon the time the condition 
comes under observation. In an acute attack, and with an 
evidently bleedihg vessel, we should follow the procedure which 
affords the most accurate and complete exposure, with the 
most ready access to the field of hemorrhage. Abdominal 
incision meets every indication, as through it we are enabled 
to see and to reach the bleeding vessel. A¥hen the patient, 
however, comes under observation a week or more subsequent 
to the hemorrhage, when the peritoneal reactive processes have 
resulted in the blood becoming encysted, and vaginal and 
abdominal palpation discloses that barriers have been formed 
by plastic exudate between the knuckles of intestine over the 
surface of the hematocele, the vaginal incision is the preferable 
procedure. This procedure is preferable for the reason that 
it respects the barriers which nature has constructed to limit 
the collection, and affords a free opportunity for the evacuation 
of the clots. They are removed by the finger and by irrigation. 
With gauze packing and a free vaginal incision the subsequent 
progress of the case is much less severe and the length of the 
convalescence is decreased. When blood has been effused 
into the peritoneal cavity and clots have formed, by neither 
the abdominal nor the vaginal method would we be able to 
remove all the clotted blood. The clotted material remains 
adherent to the sides of the sac and pelvis, and is likely in either 
procedure to cause a certain elevation of temperature as a result 
of the fermentation taking place in the retained fibrin. When 
the condition has gone on to suppuration, there should be no 
question as to the preferable procedure of reaching the collec- 
tion, when accessible, through the vagina, rather than by the 
abdominal route. It should be remembered that not all cases 
of internal hemorrhage are necessarily fatal nor require opera- 
tive procedure. If the patient is unwilling to undergo an 
operation, or the conditions do not urgently demand it, the 
promotion of absorption should be accomplished by keeping 
the patient absolutely at rest in bed, by the use of the catheter 
to empty the bladder, and by the evacuation, of the bowels 
or intestines by enemas. Absolutely interdict the use of 
opium, keep the vagina antiseptic by repeated douches, and 
when it is supposed that hemorrhage still continues, or that 
it is in danger of being renewed, apply an ice-bag over the 
abdomen, introduce ice suppositories into the rectum, and thus 
bring the ice in close contact with the bleeding vessels. In 
extraperitoneal hemorrhage indications for operation are much 
less marked. The absorption may be promoted by keeping 



582' GYNECOLOGY. 

the bowels regular and the patient at rest, and by the applica- 
tion of cold over the abdomen or of counterirritants. When 
operative interference seems indicated, the preferable procedure 
would be to make an incision through the vagina into the broad 
ligament, tear with the finger or a blunt instrument through 
the tissue of the ligament until the hematocele is reached, then 
enlarge the opening, turn out the clots, irrigate the cavity, 
and introduce gauze to afford vent for further discharge. When 
the collection is very large, it may sometimes be evacuated by an 
incision above Poupart's ligament and pushing back the perito- 
neum, the collection exposed, opened, and evacuated. After the 
cavity is thoroughly emptied, it should be packed with gauze, 
as alreadv advised. 



EXTRA-UTERINE PREGNANCY. 

546. Definition. — When the fecundated ovum does not reach 
its normal situation, — the uterine cavity, — but undergoes develop- 
ment external to it, the condition is designated ectopic gesta- 
tion or extra-uterine pregnancy, ]\Iuch difference of opinion 
exists as to the point at which the union of the spermatozoon 
and the ovum, and its consequent fecundation, takes place. 
Tait very firmly asserted that in the normal condition this 
fecundation always occurred in the uterus. Others as em- 
phatically believe that fecundation may occur at any point 
between the internal os and the exit af the ovum from the 
Graafian follicle. The recognition of the fact that in the lower 
animals the spermatozoa in normal conditions are found in con- 
tact with the ovary w^ould seem to afford justification for the 
belief that fecundation does not absolutely occur within the 
uterine cavity. Fecundation in the majority of cases un- 
doubtedty occurs in the tube, but may occur at any point in the 
progress of the ovum to the uterus. The changes which follow, 
as a result of fecundation, produce alterations in the uterine 
mucous membrane which prepare it for the reception of the 
fecundated ovum. 

547. Causes. — Much difference of opinion still exists as to 
the causes which lead to the occurrence of a misplaced ges- 
tation. Some would deny that inflammation has any part in 
its production, and would lead us to believe that the existence 
of inflammation in the tube always produces alterations which 
preclude the subsequent occurrence of pregnancy. Every ab- 
dominal surgeon of any experience, however, has seen cases 
in which well-marked tubal disease, and frequently of evident 
gonorrheal origin, has subsequently recovered, and the pa- 



EXTRA-UTERINE PREGNANCY. 583 

tients have given birth to children. During the active inflam- 
mation of such tubes the abdominal orifices are closed off by 
exudate, which, during the following resolution, may be reab- 
sorbed and afford an entrance to the tube. Those who exclude 
inflammatory cpnditions as a cause attribute the occurrence 
of ectopic gestation to congenital conditions. These consist 
of long tortuous tubes containing numerous tubal constric- 
tions, and, especially, a tubal diverticulum. It is also attributed 
to intratubular growths, which limit the caliber of the canal, 
or to growths in the tubal wall, or to pressure of growths ex- 
ternal to the tube. The hypothesis of the migration of the ovum 
from^ the ovary of one side to the tube of the opposite side 
has been well established. i\s evidence, a history is recorded 
in which an intra-uterine pregnancy occurred in a woman who 
had lost the tube of one side and the ovary of the opposite 
side. It has been supposed that the ovum, having become 
fecundated upon its emergence from the Graafian follicle, attains 
too great a size before it reaches the tube of the opposite side 
to permit of its passage down that canal. The vegetations 
upon the ovum, however, which form the chorion, do not develop 
until the ovum has come in contact with the tubal mucous 
membrane, hence this cause is of doubtful application. Every- 
one familiar with poultry is aware that occasionally an unusually 
large egg will be laid. Indeed, I have seen cases in which the 
egg was too large to pass through the canal. It is not improb- 
able that similar conditions exist in the formation of the ovum, 
and that, occasionally, an oversized fecundated ovum may 
lodge on its wa}^ to the uterus. Fright and emotional conditions 
at the time of conception are ascribed as causes. Were the 
latter, however, an important factor, tubal gestation would 
be likely to occur much more frequently in illegitimate cases. 
The study of the history of ectopic gestation long ago led 
to the recognition that a misplaced gestation was frequently 
associated with prolonged sterility. It is not unreasonable 
to believe that a period of sterility has been one in which in- 
flammatory conditions have existed and which have subsequently 
improved. Investigations of inflammatory conditions disclose 
the fact that loss of the tubal epithelium is of rather rare occur- 
rence. The existence of the gestation is due, not so much to 
the presence of patches of desquamated epithelium, as to in- 
flammatory changes which cause the canal to become narrowed, 
the folds of the mucous membrane thickened, thus rendering 
the passage of the fecundated ovum more tedious than under 
normal conditions. The expedition of the ovum to the uterus 
is also retarded by the decreased peristalsis resulting from 
hyperplasia and loss of activity in the muscular wall. Gon- 



584 



GYNECOLOGY. 



orrheal inflammation seems to have a special influence in the 
production of ectopic gestation. Thus, Prochownik found 
gonorrhea in three out of eight cases, and Ahlfeld, in the few 
cases he has observed, also attributes the condition to gonor- 
rheal infection. Ectopic gestation may occur at any period 
of the reproductive life, as in a first pregnancy or in women 
who have borne a number of children. Analysis of a large 
number of cases will show that several A^ears of previous sterility 
will occur in the majority of cases. It may occur in the first 
pregnancy of a woman who has been married eight, ten, or twenty 
years, in a woman who has not given birth to a child for five or 
six years ; or, again, it may follow immediately after a labor or 
abortion. Furthermore, it may occur in the newly made bride or 
in the unmarried. Both tubes may be pregnant concurrently 
or one tube may contain a tubal pregnancy or a tubal may com- 
plicate a uterine pregnancy. Cases have been reported in which 




Fig, 440. — Tubal Pregnancy. 

there occurred a twin pregnancy in the outer portion of the tube, 
and an interstitial or single pregnancy in the uterine end, making 
three embryos in the one tube. Dr. Wilmer Krusen has reported 
a tubal pregnancy which had ruptured, and in the sac three fetuses 
were found. 

548. Varieties. — Ectopic gestation is most frequently found 
to be of the tubal variety. Some undisputed cases of ovarian 
pregnancy have been described, but when we consider the fecun- 
dated ovum and the conditions necessary for its nutrition and 
development, it is evident that the ovum rarely develops when 
not in contact with the Miillerian mucous membrane. It is 
quite probable that many of the cases described as ovarian preg- 
nancy have been originally tubo-ovarian and have become 
separated from their tubal relation. Tubal gestation occurs 
most frequently in the central portion of the tube. (Fig. 440.) 
It may be situated toward its abdominal end, and as it de- 



EXTRA-UTERINE PREGNANCY. 



585 



velops, is extruded or partly extruded and comes in contact with 
the ovary, when it is known as tubo-ovarian pregnancy. (Fig. 
441.) When situated within the central portion of the tube 
■or ampulla, it is known as ampullar or tubal pregnancy. To- 
ward the uteri*ne end, or that portion which passes through 
the uterine wall, it is known as tubo-uterine or interstitial 
pregnancy. (Fig. 442.) Rupture of a tube with partial escape 




Fig. 441. — Tubo-ovarian Pregnancy. 

of the ovum, which retains its placental attachment, may sub- 
sequently develop, when it becomes an abdominal pregnancy. 
Abdominal pregnancy, therefore, is secondary and not primary. 
The reimplantation of the ovum upon the peritoneal surface 
and its subsequent development have been asserted to be an 
impossibility, but when we find the tube having no longer any 




Fig. 442. — Tubo-uterine or Interstitial Pregnancy. 



relation or connection with the sac, the placenta situated, as 
in the case of Tuholske, upon the liver, and apparently upon 
the folds above it, it seems impossible to explain its occurrence 
upon any other ground than that of reimplantation. 

549. Course and Progress. — The fecundated ovum lodged 
in the tube finds a condition different from that of the ovum 
within the uterine cavity. In the latter, the mucous membrane 



586 GYNECOLOGY. 

consists of glandular or lymphoid tissue, which becomes thickened 
as a preparation for the reception of the fecundated ovum, in 
which the trophoblast cells of the ovum enable it to sink in 
and become embedded. The syncytial cells in the chorion 
arise from the trophoblast cells, and the uterine epithelium 
in no sense plays any part in their production. In the tube it 
meets with an entirely different condition. There are no glands, 
and there is much difference of opinion as to the formation 
of the decidua. This, in the uterus, consists of a compact and 
spongy layer, but in the tube, of a compact layer only. The 
decidua cells are found not so much in immediate contact with 
the wall of the tube as at either end of the sac. Bandler, in his 
investigations on the development of ectopic gestation, divides 
it into three types : ( i ) The columnar type of tubal gestation ; 
(2) the intercolumnar ; and (3) the centrifugal, (i) In the 
columnar variety, at no point in the tube wall or in the mucosa 




Fig. 443. — Tubal Abortion. 

is there any decidual change or any condition representing the 
trophoblast cells or villi, consequently no decidua or tropho- 
spongia develops. The ovum is surrounded by mucous folds 
and only an invasion of the tubal capillaries follows. Abor- 
tion in these cases is easy and causes but little danger ; bleeding 
occurs ; the fetus dies, and further hemorrhage expels it. The 
tube may subsequently become normal or a hematosalpinx 
may follow. (Fig. 443.) (2) In the intercolumnar type one- 
half of the tube is normal, the other torn and infiltrated, the 
mucous folds are involved down to the muscularis. The ovum 
is situated upon the tube wall, where it compresses and destroys 
the folds at the situation known as the serotina. These folds 
are united at either side about the ovum, forming a pseudo- 
refiexa. Some distance on either side of the serotina, tissue 
resembling decidua, with closely grouped cells without capil- 
laries or spaces, rests upon and invades the free surfaces. The 



EXTRA-UTERINE PREGNANCY. 587 

invasion traverses the mucosa in irregular branches or pro- 
jections about the blood-vessels, invading and infiltrating 
their muscular walls up to and into the lumen. Trophoblast 
cells are accompanied by sync}^ium, but at no point do the 
connective -tissue cells, the tubal folds, or the delicate sub- 
mucosa, if present, exhibit any evidence of change which re- 
sembles in the slightest degree those occurring in the uterine 
mucosa, from which the decidual cells develop. Neither is there 
at any point any change of a so-called syncytial character. 
The ovum rests upon the wall, and the tubal fold immediately 
beneath it will be compressed, but the epithelium may remain 
in the depressions. Other folds may form a capsularis, which 
consists of mucosa alone. An intervillous space may develop 
when the capsularis is formed. The villi at the placental site 
enter the wall, and hemorrhage follows, especially upon the 
invasion of vessels of the capsularis by fetal cells. The preg- 
nancy may terminate in abortion, complete or incomplete, 
the latter usually being the rule. If the abdominal end is 
closed, a hematosalpinx or tubal mole may follow. (3) The 
syncytial type. In this the tissue of the tube is invaded by 
villi cell groups — syncytial cells. Here again there is no evi- 
dence of a decidua or of any decidual reaction. When unin- 
terrupted, the capsularis unites with the mucosa of the envelop- 
ing tube wall in the same way that this process is exemplified 
in the uterus. The centrifugal ovum sinks into the wall of 
the tube, when invasion of the wall and vessels by the villi 
occurs. Rupture may take place at the summit or hemorrhage 
from invasion of the vessels entering into the intervillous spaces. 
Bleeding from the villi penetrates the serosa and rupture at 
the placental site may follow, or we may have multiple per- 
foration and erosions. The ovum apparently eats up the tube 
wall and its destruction is not the result of pressure. In such 
cases the perforations may be so minute as only to be revealed 
by a microscope. The death of the ovum may not arrest the 
growth of the villi. This form furnishes the majority of cases 
of rupture. Very frequently the hemorrhage is due not to 
rupture, but to the erosions from the perforating villi. The 
presence within the tube of the developing ovum causes the entire 
structure to become turgid and vascular. There is some tendency 
in the tube to the development and extension of its structure, 
but to a much less degree than in the uterus. The wall becomes 
stretched, attenuated, and thin. The mucous membrane is 
stretched and its folds effaced. As the tubes vary in length 
and thickness, the rapidity of thinning correspondingly differs. 
When the ovum is situated in the outer third, changes follow 
in the ostium. In the first four cases the fimbria are sw^oUen, 



588 GYNECOLOGY. 

turgid, and the congestion extends to the adjacent muscular 
and serous tissue; the fimbria are gradually retracted, while 
the peritoneal margin of the ostium forms an irregular ring, 
which in four and one-half weeks projects beyond the ends 
of the fimbria. It finally contracts, and at the end of the eighth 
week is completely contracted and hermetically sealed. The 
occlusion, however, is not constant. Occasionally the ostium 
dilates. The nearer the ovum is situated to the abdominal 
end, the less likely will it be to become closed. As the tube dis- 
tends, its vessels ruptiue and hemorrhage takes place, which fills 
up the sac and may cause the extrusion of the ovum. The 
more firmly the tubal end becomes occluded, the greater the 
danger of tubal rupture. Its situation near the abdominal 
ostium favors its extrusion through the opening into the ab- 
domen as a tubal abortion. ]\Ioles occur in tubal as in uterine 
gestation; indeed, they are more frequent in the former. They 
vary from one to eight centimeters in diameter and are glob- 
ular or ovoid, assuming the latter shape in the larger varieties. 
The tubal moles are formed by hemorrhage, which occurs in the 
subchorionic diameter, between the chorion and the amnion. 
This hemorrhage may be gradual or sudden, and results in 
the death and often in the disappearance of the embryo. The 
puerperal origin of the condition in the absence of any vestige 
of the fetus is recognized by the discovery, with the micro- 
scope, of the chorionic villi. The outer investing membrane, 
the chorion, is generally shaggy, with villi, which are rendered 
more visible by washing the clot under a gentle stream of water. 
When the amniotic cavity is obliterated, doubt may exist 
as to the character of the mass, but section will disclose the 
villi in clusters as small circular bodies. Tubal abortion has 
been mentioned as one of the terminations of tubal gestation, 
when the developing embryo occupies the external third of 
the tube. The nearer the fecundated ovum is situated to the 
ostium, the greater the danger of its extrusion. As the em- 
bryonal sac increases to a size beyond that which the tube is 
able to accommodate, it is pushed out through the funnel- 
shaped cavity and escapes into the abdomen. This accident 
is denominated tubal abortion, and is frequently associated 
with profuse hemorrhage, which is very similar to that which 
occurs in uterine abortion. The mole is discharged with copious 
hemorrhage into the peritoneal cavity. This displacement is 
likely to take place during the first two months of the preg- 
nancy. When the ostium is closed, blood escapes from the tube 
only after rupture of the sac. The quantity of blood discharged 
is sometimes enormous and attended with all the symptoms 
of internal hemorrhage. This condition is one of the most 



EXTRA-UTERINE PREGNANCY. 589 

frequent causes, of pelvic hematocele. Internal hemorrhage 
in such cases has been ascribed to metrorrhagia, to reflex men- 
strual discharge from the uterus, or to hemorrhage from the 
Fallopian tube. The reason why it has been associated with 
metrorrhagia is, that while the embryo is developing in the tube 
a decidua is forming in the uterus. With a tubal abortion, 
hemorrhage occurs from the uterus as a result of the separation 
and the expulsion of this decidua. This not infrequently 
happens near the time the patient expects to menstruate, and 
is, consequently, regarded as reflux menstrual fluid. Very 
frequently the bloody discharge from the uterus may be derived 
from a gravid tube in protracted tubal abortion. If the bleed- 
ing occurs at a time not synchronous with the menstrual flow, 
it is often attributed to a disorder of the uterus. In all such 
cases the affected tube and the bloody discharge should be 
carefully examined for the presence of the embryo or the chor- 
ionic villi. The abortion may be complete or incomplete — 
complete when the embryo and its envelope are discharged; 
incomplete when a portion remains attached to the tube. The 
latter is the more common. The danger is increased in these 
cases, owing to the fact that the bleeding is apt to recur while 
the mole is retained. The villi will be disclosed by careful 
microscopic examination of the extruded mass and are dis- 
covered in sections of the adherent pole of the mass. 

A third termination of tubal gestation is that of rupture. 
As the embryo develops, the tube becomes more and more 
thinned, until it is no longer able to resist the inward pressure, 
and rupture results. Rupture of the gestation sac may be 
considered under: flrst, primary rupture; second, secondary 
rupture — each of which may be intraperitoneal or extraperi- 
toneal. Primary rupture takes place at any time between 
the third and tenth weeks after impregnation, and is rarely 
deferred beyond the twelfth. Predisposing causes of rupture 
are the gradual thinning of the gestation sac by the gro^vth 
of the ovum or the undue distention of the membrane by 
hemorrhage, especially at the seat of implantation of the chori- 
onic villi. The perforation of the tubal wall by the villi 
may be excited by violence, as jumping from a train, strain- 
ing at stool, jarring of a carriage, vomiting, or sexual congress. 
Rupture may occur as a result of eft'orts to determine the diag- 
nosis. 

It was my misfortune to see a case of this kind in which 
the examination by myself, and subsequently by the attending 
physician, was followed within a few minutes by symptoms 
of profound collapse, which confirmed the suspicion that an 
extra -uterine pregnancy was present. As soon as permission 



590 , GYNECOLOGY. 

could be secured the abdomen was opened, to find half a gallon 
of liquid blood within it; and although the vessel was secured, 
and every measure taken to restore the patient, she succumbed 
to the shock. 

The tube is enveloped in two-thirds of its circumference 
by the peritoneum, which forms a mesosalpinx; as the tube 
is enlarged by the developing embryo the mesosalpinx sepa- 
rates. This condition is true only of the internal two-thirds 
of the tube. The external third is not supplied with the meso- 
salpinx. The intraperitoneal rupture is three times as frequent 
as the extraperitoneal. In primary intraperitoneal rupture the 
embryo and its enveloping membranes, or a mole, are dis- 
charged into the abdominal cavity, and a certain amount of 
hemorrhage follows. The amount of blood extravasation 
will depend upon the period of pregnancy when the rupture 
occurs; when early, it may be slight. After the first month, 
however, it is copious — frequently sufficient to cause death 
in a few hours. I saw one patient who had missed her period 
but five days. She was taken with violent pain at night, fainted 
several times, and was seen and subjected to operation the 
following morning. She was then extremely anemic, and the 
abdomen was found filled with a large quantity of blood, 
which had escaped from a cyst not larger than a bean in the 
left Fallopian tube. The ligation of the bleeding vessel and 
the removal of the extravasated blood resulted in her restora- 
tion to health. Frequently the hemorrhage may be so great 
as to cause a fatal result in a few hours; in some cases even 
in half an hour.. AVhen a rupture is deferred until the seventh 
week, the embryo or mole is not constantly discharged through 
the opening. The quantity of blood which escapes may be 
very large, and demand immediate attention, or it may be 
slight in character, permitting the patient to escape the im- 
mediate dangers incident to the accident with but slight shock. 
The effused blood can undergo absorption and recovery ensue. 
When the discharge is not excessive, the blood collects in the 
rectovaginal fossa and fioats the coils of intestine, forming an 
intraperitoneal hematocele, as has been described. Dangers of 
the primary intraperitoneal rupture are: first, hemorrhage 
so great as to cause immediate death; second, the fatal result 
may be occasioned by repeated hemorrhage. In primary 
extraperitoneal rupture that portion of the tube not covered 
by peritoneum gives w^ay and permits the discharge of the 
ovum and the accompanying blood between the layers of the 
mesosalpinx. Here the blood is forced into the connective 
tissue between the layers of the broad ligament, and, fortu- 
nately for the patient, the bleeding is checked by the pressure 



EXTRA-UTERINE PREGNANCY. 591 

from the resisting tissues, and is generally arrested before it 
assumes dangerous proportions. This lesion rarely causes 
trouble. Occasionally, the rupture of the tube is slight, the 
embryo partly escapes, with its membranes remaining un- 
injured, and tjie pregnancy will continue. Rupture affords 
increased space for further' development, and, the power of 
resistance being decreased, the ovum, as it increases in size, 
burrows between the layers of the broad ligament. The rup- 
ture may be gradual; the tube does not split suddenly, but 
as its walls, through the gradual distention, become thinned, 
they yield in the part uncovered by peritoneum until an open- 
ing forms and the ovum is extruded, accompanied by sudden 
hemorrhage. The extent of collapse and its duration will be 
largely dependent upon the amount of blood effused. The 
artificial opening gradually extends, the embryo and placenta 
make their way into the new area, and, unless the hemorrhage 
be sufficient to terminate the life of the embryo, the pregnancy 
is continued. This is known as a mesometric or an intraliga- 
mentary gestation. In this anomalous development of the 
ovum the placenta is liable to many changes which will vitally 
influence the life of fetus and mother. The tubal mucous 
membrane, as has been mentioned, plays a very insignificant 
part in the formation of the placenta. The latter is developed 
mainly from the fetal tissues, as the tube does not develop a 
decidua. With the fecundation of the ovum there are at once 
developed changes in the uterine mucosa in preparation for 
its retention and sustenance. When the fecundated ovum 
is arrested in its progress and prevented from entering the 
uterus, the uterine decidua continues to develop as if it were 
normally placed. This decidua, however, is rarely retained 
until the completion of gestation, but is thrown off during 
the false labor; not infrequently, when the individual suffers 
from symptoms of tubal abortion or tubal rupture. The oc- 
currence of this profuse bleeding after one or two months' amen- 
orrhea, with the discharge of a cast or of shreds of tissue from 
the uterus, which may frequently be enveloped in a large clot, 
leads the patient and her attendant to believe that a uterine 
abortion has occurred. When the individual goes to term, 
the uterine decidua is thrown off as a cast or in shreds during 
the early months of the pregnancy. When the decidua is 
discharged' in small fragments, it takes place without unusual 
pain; but en masse, the symptoms are similar to those of a 
miscarriage. The absence of the uterine decidua at the death 
of the ovum from rupture of the cyst, even in the early stages 
of pregnancy, is no proof that the membrane has not existed 
and been expelled before fetal death. When pregnancy occurs 



592 



GYNECOLOGY. 



in one-half of a bicornate uterus, the decidua is present in the 
unimpregnated cornu. Under no circumstances, however, either 



in the normal or abnormal pregnancy, 




Fig. 444. — Complete Rupture of a Tubal Sac. 



is a decidua found in 
the Fallopian tubes. 
As the destructive- 
changes of the mucous 
membrane of the gen- 
ital tract associated 
with menstruation are 
limited to the uterine 
cavity, so the true 
decidua is found in the 
same portion. It is 
sometimes important 
to avoid confounding 
the decidua of preg- 
nancy w4th the cast 
thrown off from the 
uterus in membranous 
dysmenorrhea. In the 
former it consists of 
a compact layer of 



decidual cells. In the 
latter, the cast is more 
likely to involve a portion of the glandular structure of the 
uterus. 

Rupture may be complete or incomplete. Complete rup- 
ture is one in which the ovum and its envelopes escape, either 
into the peritoneal 
cavity or into the 
broad ligament, with 
more or less profuse 
hemorrhage. (Fig. 
444.) A partial rup- 
ture may result in the 
gradual thinning of 
the wall until it gives 
way in one place ; and 
when this takes place 
extraperitoneally, it is 
reinforced by plastic 
exudate, with the oc- 
currence of but little, 

if any, hemorrhage. (Fig. 445.) Successive ruptures or partial 
ruptures thus occur until finally the envelope becomes sufficiently 
distended to permit the fetus to develop as in an intra-abdominal 




Fig. 445. — Incomplete Rupture of Gestation Sac. 



EXTRA-UTERINE PREGNANCY. 593 

pregnancy. At no time during such a rupture has the separation oc- 
curred between the placenta and the tube. In the extraperitoneal 
variety the embryo and placenta gradually occupy a sac formed 
by the expanded tube and separated layers of the broad ligament. 
The floor of this space is formed by connective tissue and the leva- 
tor ani muscle. The ultimate effects depend to a great extent 
upon the original situation of the placenta. When the embryo 
is situated above the placenta, the latter is depressed between 
the layers of the broad ligament until it is arrested by the pelvic 
floor. If the embryo lies below, and the membranes burrow 
between the layers of the broad ligament, the placenta is pushed 
up until it lies high in the abdomen. As there is no tubal decidua, 
the placental villi lie embedded in the decidual cells without 
any intervillous system existing. When the placenta is dis- 
placed into the tissue of the broad ligament, which occurs 
gradually, its structure becomes seriously damaged: the villi 
are less perfect in their contour, points of extravasation of blood 
are present, and blood-crystals are abundant. Finally, tmder 
the pressure, the placenta becomes gradually reduced to a 
mass of compressed villi ; its serotina is destroyed and is replaced 
by blood-crystals and by organized blood-clot. While the 
consequences to the placenta from its displacement into the 
tissue of the broad ligament are thus marked, it is not attended 
with nearly so much danger as when the placenta is situated 
above the embryo. It is then subject to extreme disorganiza- 
tion, forming, as it does, the roof of the gestation sac. The 
changes that take place in the placenta, owing to the pressure 
of the developing fetus, have a great influence on the sub- 
sequent history of the pregnancy, adding to a marked degree 
to the peril to the life of the mother, and are, in the majority of 
cases, disastrous to the life of the fetus. The constant tension 
to which the peritoneum covering the gestation sac is subjected 
leads to partial detachment of the placenta and to severe hemor- 
rhage, either into the gestation sac or into the peritoneal cavity. 
In the later stages of the pregnancy such hemorrhage is al- 
most invariably fatal. A w^oman with an intraligamentary 
pregnancy, with a placenta situated above the fetus, runs a 
greater risk of losing her life than she would from placenta 
previa. A tubal placenta which is situated above the embryo 
has its structure so damaged by rupture as to render it an in- 
efficient respiratory organ; and the constant results upon the 
embryo are very marked. The fetus from such a gestation 
is rarely a satisfactory individual. It is very unusual for the 
fetus to live longer than a few days or weeks subsequent to 
its delivery. Not infrequently it is ill formed, suffering with 
hydrocephalus, club-foot, spina bifida, ectopia of the viscera, 
38 



594 GYNECOLOGY. 

and other deformities. When normal in shape, it is exceed- 
ingly defective in size. One case is recorded in which the 
tubal sac contained two embryos, measuring eleven centimeters 
in length, which were united by a band in the thoracic region. 
Dr. M. Price reported a well-formed ectopic fetus which sur- 
vived operation and was subsequently healthy. The amount 
of hemorrhage in an incomplete rupture will depend much 
upon the situation of the placenta. If the placenta be at- 
tached to the peritoneal surface and rupture takes place over 
it, the bleeding will be excessive and will possibly result in the 
death of the patient unless surgical intervention prevent. 
If the placenta is situated on the opposite side to that on which 
rupture occurs, the envelopes may protrude, but little bleed- 
ing will follow, and the sac becomes reinforced by plastic exu- 
date and adhesions. The sac wall is then formed by the uterus, 
the bladder, the parietal or pelvic peritoneum, and the coils 
of intestine. 

Secondary Rupture. — The extraperitoneal rupture causes 
the formation of a secondary broad-ligament gestation sac, 
which increases in size and may subsequentty undergo rupture. 
As has already been indicated, the danger is much increased 
when the placenta is situated above the fetus. As the preg- 
nancy progresses the peritoneum becomes stretched and is 
separated from the adjacent parts and from the viscera. The 
sac extends into the abdomen, and strips the peritoneum from 
the anterior abdominal wall to a greater degree than would 
an overdistended bladder. When the posterior peritoneum 
is thus raised up, the rectum, as well as the posterior surface 
of the uterus, may be deprived of serous investment. The 
placenta is insinuated between these parts, and secondary 
rupture may result at any time between the twelfth week and 
the completion of term. The effects of this secondary rup- 
ture are dependent upon the injury to which the placenta is 
subjected. After the middle period of pregnancy has passed, 
when it involves the placenta, — as it almost certainly will, 
situated, as the latter is, above the fetus, — most frightful hemor- 
rhage and rapid death will be the consequence. Earlier in the 
course of the pregnancy the hemorrhage is not so severe, and 
may be arrested by prompt surgical intervention. Opening 
of the sac into the peritoneal cavity is recognized as secondary 
intraperitoneal rupture. If the fetus occupies the upper por- 
tion of the sac and the placenta is attached below, the former 
may escape among the intestines. Secondary rupture does 
not always occur. The patient may go to term, spurious labor 
follow, the liquor amnii be absorbed, and the placenta dis- 
appear. If the extra-uterine pregnancy has not been sus- 



EXTRA-UTERINE PREGNANCY. 595 

pected and its course not disturbed, the formation of a mum- 
mified fetus, or lithopedion, results, which may be discovered 
years later. Secondary intraperitoneal rupture may occur 
at any time between the twelfth week and term. When it 
occurs at or near term, the belief is perpetuated that the fer- 
tilized ovum had tumbled into the peritoneal cavity, to in- 
graft itself upon the serous membrane and there develop. It 
should be understood, however, that there is no primary peri- 
toneal pregnancy, but that the condition originally developed 
in the Fallopian tube. When the pregnancy develops in the 
uterine end of the tube, particularly that portion which traverses 
the uterine wall, it is termed a tubo-uterine pregnancy. This 
form of pregnancy is not frequent, and can readily be confounded 
with pregnancy in one cornu of a bicornate uterus. The tubo- 
uterine gestation differs in its course, relations, and mode of 
termination from the purely tubal form. Primary rupture 
generally occurs before the eighth w^eek, and the pregnancy 
is rarely continued without rupture beyond the twelfth week. 
The tubo-uterine gestation sac may rupture in two directions: 
into the peritoneal cavity, causing frightful hemorrhage and 
a rapidly fatal result, or, resistance being slighter toward 
the uterine cavity, the fetus and envelopes may be pushed 
into the uterus and terminate as in an intra-uterine conception. 
The intraperitoneal rupture is much more rapidly fatal than 
in the tubal form, and causes more severe hemorrhage, because 
the uterine wall is more vascular and the sac is situated in 
closer apposition to larger vessels. Tubal and tubo-uterine 
pregnancy have the following distinctive characteristics: the 
tubal pregnancy is very common, the tubo-uterine rare; the 
tubal gestation sac is ver}^ thin, the tubo-uterine very thick. 
The termination can be: (a) Intraperitoneal rupture for 
each, or (b) rupture into the intraligamentary space. In the 
tubo-uterine, rupture can occur into the uterine cavity, with 
the discharge of the fetus through the vagina, (c) In the tubal, 
abortion can result, and, as in the primary rupture, date from 
the third to the tAA^elfth week. In the tubo-uterine, rupture 
occurs at any time from the fifth to the twentieth week. Ovarian 
pregnancy, pure and simple, is extremely rare, and while there 
are cases in which careful examination has disclosed ovarian 
structure in the sac wall, w4th the tube free and unaffected, 
yet we are not prepared to admit that the condition may not 
have originated from the tube, for it is very doubtful whether 
the ovum w411 develop when not attached to the ]\Iullerian 
structure. The majority of cases of ovarian pregnancy are 
undoubtedly tubo-ovarian, in which the embryo was originally 
situated in the orifice of the tube and has been partly extruded 



596 GYNECOLOGY. 

without loss of its vitality. As would be readily inferred, 
the life of the embryo in a tubal pregnancy is necessarily pre- 
carious. Aitev rupture, undoubtedly the pregnancy may con- 
tinue until full term. Symptoms of labor set in, during which 
the gestation sac may burst into the peritoneal cavity, or, 
if this catastrophe is avoided, the fetus dies. The body re- 
mains quiescent or produces various forms of disturbance. 
Thus, the liquor amnii is absorbed; the tissues of the fetus 
become mummified or partly calcified, and form a lithopedion. 
The softer parts are converted into adipocere or undergo other 
forms of decomposition. The placental tissue is gradually 
absorbed and disappears. 

Mummification. — The process of mummification is attended 
with absorption of the fluids, while the soft parts are converted 
into a dried tissue similar to that which follows when a dead 
cat is permitted to remain under an old building, producing 
a dried cat. An extra -uterine fetus can be retained in the 
body for a long period of time. Cheston reports a lithopedion 
carried for fifty-two years; Barnes, one forty-two. The pos- 
sibility of the fetus being carried this length of time does not 
necessarily indicate that it can not prove a source of danger 
to the patient. Pathogenic micro-organisms can find entrance 
to the sac through the adjacent hollow viscera, and at any 
time produce serious trouble. Suppuration follows, and pus 
finds its way through the sac- wall, and penetrates the va- 
gina, uterus, bladder, or rectum. Through any of these open- 
ings fragments of fetal tissue from time to time escape, caus- 
ing frightful distress and necessitating operation for relief. 
The existence of a lithopedion or macerated fetal skeleton 
does not preclude subsequent pregnancy. One case came 
under my observation in which a woman with a good-sized and 
distinctly well-defined lithopedion subsequently gave birth to 
two children. 

550. Symptoms. — The symptoms which should lead one to 
suspect the existence of an ectopic gestation are dependent upon 
the duration and course of the pregnancy. A history will be 
obtained of disordered menstruation, the patient having missed 
one or more periods. The ordinary symptoms of pregnancy are 
present and she has supposed herself pregnant. She may have 
experienced a sensation of uneasiness or distress over the region 
of the ovary and tube upon one side, associated with frequent 
and sudden attacks of colicky pains. These pains may have been 
of severe, cutting character, paroxysmal, and occasionally quite 
intense. In other cases without any premonition pain of a tear- 
ing, cutting character will occur, so severe and lancinating as to 
cause the patient to fall and become unconscious. This phenom- 



EXTRA-UTERINE PREGNANCY. 597 

enon may be followed by repeated attacks of syncope in which 
the countenance of the patient becomes pale, anxious, covered 
with clammy perspiration, lips pale and blanched, respiration 
sighing, the sight obscured, sensation of darkness or even blind- 
ness, mind frequently AA^andering, or she may remain unconscious 
or pass from one attack of syncope to another. The pulse at the 
wrist becomes exceedingly feeble, faint, and imperceptible. The 
temperature is subnormal, and all the indications of approaching 
dissolution are present. Generally the symptoms are not so 
marked or the patient is weak, debilitated, shoAvs symptoms of 
shock or collapse, soon rallies, AAdth recurring attacks of a similar 
character, AA^hich indicate that the hemorrhage has again recurred 
or is sloAAdy continuing. In other cases the progress is insidious. 
A small aperture exists; the AA^alls have been stretched. Plastic 
exudation is throAvn out and the pregnancy ma}^ progress AA^thout 
further accident. The tube may rupture either intraperitoneally 
or extraperitoneally. The symptoms of the tAvo varieties Avill 
be found entirely different. The graAdty of the former is much 
the greater, but will depend upon whether the rupture has been 
complete or incomplete, and also upon the situation of the 
placenta. When the rupture occurs from the site of the placenta, 
CA^en though incomplete, hemorrhage can be so scA^ere as to cause 
the death of the patient if inter A^ention is not instituted. Ac- 
cording to the intensity of the hemorrhage, the patient may either 
die in the first attack, that is, AA'ithin half an hour or an hour after 
the first symptoms, or slightly rally and an apparent recurrence 
of the hemorrhage folloAA- , AA^th death AA^thin less than tAventy- 
four hours. Should the patient surA^iA^e tAA^enty-four hours and 
rally, her strength may gradually return and recoA^ery folloAA^ or a 
secondary hemorrhage may dcA^elop and result in a fatal termina- 
tion. AYhen the patient survi\^es the hemorrhage and shock, the 
accident is folloAA^ed by more or less tenderness OA^er the abdomen 
and by abdominal distention, AA^hich symptoms indicate the oc- 
currence of localized peritonitis. In the early stage of hemor- 
rhage no physical signs of its existence can be recognized. Pos- 
sibly a large quantity of blood in the abdominal caA'ity of a thin 
woman could be recognized by the sensation of fluctuation. In 
tAA^enty-four hours the blood aa^II accumulate in the peh^s, and 
AA^e then obserA^e a sensation of fluctuation and slight resistance 
by A^aginal palpation. Change in the position of such a patient per- 
mits the collection to floAV out of the peh'is, AA^hen its presence Avill 
no longer be recognized. If the pelvis is again loAA^ered, the accu- 
mulation returns. The coagulated blood causes more or less irri- 
tation, which results in the exudation of plastic material and the 
occurrence of a localized peritonitis. The abdomen becomes tender 
to the touch, febrile reaction occurs, the temperature instead of 



598 GYNECOLOGY. 

being subnormal now rises to ioi° F. or even 103° F. The patient 
may experience distress from pressure of the mass on the rectum 
or against the uterus and bladder, which produces frequent 
micturition or even incontinence. With the advent of plastic 
peritonitis the collection becomes encysted; the patient will 
often suffer from nausea and abdominal distention. The watery 
portions in such a collection become gradually absorbed and the 
mass is more apparent and resistant. The uterus may be pushed 
upward and forward. The intestines are raised up and form a 
part of the wall of the sac. The collected mass varies in its con- 
sistence: sometimes it is hard, at others soft, or the same mass 
may have several points of softening. The uterus may be envel- 
oped by the collection, producing w^hat is known as an enveloping 
uterine hematocele ; the functions of the rectum and bladder may 
be greatly impaired by the compression of the mass against these 
organs, which may often cause symptoms of intestinal strangula- 
tion and retention of urine. Pressure upon the nerves of the 
pelvis frequently gives rise to severe neuralgia of the lower ex- 
tremities. Even when suppuration does not occur, irregular 
attacks of fever are frequently the result of peritoneal reaction. 
The course and progress of the disease are essentially chronic, or re- 
peated attacks may occur. The congestion which takes place at 
the menstrual periods may result in acute symptoms. Sup- 
purative change in such a collection is ushered in by an aggrava- 
tion of both the local and general symptoms, chills, elevation of 
temperature, profuse sweating, increased leukocytosis ; the tumor 
increases in size and undergoes softening; the mass may sub- 
sequently perforate into the rectum, causing the evacuation of 
dark, purulent, exceedingly oft'ensive material in the stools, 
which may cause more or less irritation of the rectum. These 
discharges are followed by cessation of or disappearance of the 
tumor. Perforation into the vagina or bladder may occur, though 
these are rare. Perforation into the abdominal cavity is for- 
tunately infrequent. When it does result, a violent attack of 
general peritonitis follow^s. The occurrence of rupture of the 
tubal sac is not infrequently associated with discharge of blood 
from the vagina and with severe uterine pain. The uterine pain 
or the pain from the rupture may cause the victim to believe that 
an abortion is impending. This suspicion may be still further 
confirmed by the discharge of a cast from the uterus or of shreds 
of tissue, associated with clots, which may lead both the patient 
and her medical attendant to believe that an abortion has 
occurred. When the hemorrhage is slight and the ovum retains its 
connection w4th the tube, the fetus may continue to full devel- 
opment, and even reach full term. A pregnancy situated pos- 
terior to the uterus may reach full term without causing the 



EXTRA-UTERINE PREGNANCY. 599 

patient to suspect that an abnormal condition exists, and it is 
only after the beginning of labor, when an examination is miade, 
that the true state of affairs is recognized. Even then it is not 
always recognized and the spurious labor. may terminate without 
the discharge of the fetus and the sac may undergo subsequent 
changes. 

551. Diagnosis. — Diagnosis comprises: (i) The recognition 
of extra-uterine pregnancy prior to rupture ; (2) the determination 
of rupture or abortion with intraperitoneal or extraperitoneal 
hemorrhage and death of the fetus; (3) secondary rupture; 
(4) continued growth of the embryo after rupture; (5) peritonitis; 
(6) suppuration. 

I. Preceding Rupture. — ]\Iost frequently the victim of mis- 
placed conception does not apply to her physician until the oc- 
currence of a violent, tearing pain, associated with rupture. The 
distressing symptoms are rarely sufficiently definite prior to this 
occurrence to demand a physical examination. Such an examina- 
tion is generally requested in order to ascertain the existence of the 
supposed normal pregnancy. The frequent occurrence of ectopic 
gestation, however, should lead to the careful investigation of 
every patient who gives symptoms of being pregnant, where 
there is a previous history of more or less extended sterility, 
of attacks of pelvic inflammation, and, especially, if the latter 
has originated from gonorrheal infection. Such an examina- 
tion is particularly indicated when the patient, having missed 
a period, complains of a sensation of uneasiness or distress in 
one side of the abdomen, associated with frequent and' sudden 
attacks of colicky pain. Every such patient should be sub- 
jected to a careful examination. Slight enlargement of the 
uterus, with some tenderness in the pelvis, more marked upon 
one side, associated with a more or less spherical or rounded 
distention of the tube, should increase the suspicion of ectopic 
gestation. This suspicion would be confirmed by finding 
increased vascularity in the broad ligament, causing marked 
pulsation of its vessels. This pulsation is distinctly recogniz- 
able upon the affected side, while the pulsation on the opposite 
side is not defined. The examination should be made with 
the utmost gentleness, for rough manipulation or marked pres- 
sure in the practice of the bimanual procedure can very readily 
rupture a sac which is so thin as to require only a slight amount 
of additional pressure. AVhere the sac is of considerable size, 
it is unwise to subject it to much force in the examination, un- 
less the operator is prepared for immediate operation should 
rupture occur. It has been my unfortunate experience with 
a patient in whom the pulsation was as distinct as if the finger 
were placed over the radial artery, to have the sac ruptured 



600 GYNECOLOGY. 

by her physician, who was desirous of examining the case. 
The patient succumbed to the subsequent operation. Dr. 
J. M. Fisher, my assistant, reports two cases in which he has 
observed the rupture of an ectopic gestation during examination. 
2. Rupture. — The rupture of an ectopic gestation sac may 
be suspected when the patient gives a history of having failed 
to menstruate for one or two periods and has exhibited the 
ordinary symptoms of pregnancy. She has probably had 
more or less discomfort upon one side, with frequent colic k}^ 
attacks, when suddenly, without warning, there has been an 
attack of most violent, tearing pain, followed by syncope, all 
the symptoms of internal hemorrhage, with oncoming collapse. 
I have seen such a patient in the space of ten minutes pass 
from a condition of apparent good health to one which seemed 
to threaten approaching dissolution. The face was blanched, 
pale, exceedingly anxious looking, covered with cold, clammy 
perspiration; pupils dilated, eyes expressionless, rolling from 
side to side; sighing respiration; pulse rapid, feeble, some- 
times almost imperceptible; patient complaining of being un- 
able to see, and everything appearing dark about her. Some- 
times marked nausea and vomiting are present. The slightest 
movement, even raising the head of the patient, is followed 
by more or less profound syncope. The occurrence of such 
a train of symptoms should awaken in the mind of the ob- 
server the absolute conviction that an internal hemorrhage 
is occurring, and the association of such a group of symptoms 
would indicate its origin from an ectopic gestation. A phy- 
sical examination affords very little information, for at this 
time the tumor is insufficiently large and without the necessary 
firmness to afford the sensation of resistance. The physical 
signs are consequently indefinite. When the bleeding is ex- 
tensive, the abdominal walls thinned and not very resistant, 
a sensation of distention may be noted and even fluctuation 
recognized. When the hemorrhage is not so profound as to 
endanger life, the watery portions of the effused blood are 
gradually absorbed and leave a more or less resistant clot, 
which can be felt as a firm mass in the pelvis. In the absence 
of previous history of recent inflammatory trouble or the pre- 
vious existence of a growth, it must be recognized as effused 
or clotted blood. The accumulation is generally retro -uterine. 
A large extravasation may fill the pelvis, push the uterus for- 
ward, and raise the intestines above it (Fig. 438). In other 
cases the uterus may be found in a state of retroversion, while 
a mass is situated in front and forms an ante-uterine hemato- 
cele; or in very large accumulations the uterus may protrude 
through it, producing what is known as a circumuterine hemato- 



EXTRA-UTERINE PREGNANCY. 601 

cele. Hemorrhage dangerous to life, and productive of the 
most profound anemia, may arise without rupture, as in tubal 
abortion, or when the villi have penetrated the wall of the 
tubal sac and bleeding occurs from their surfaces. These per- 
forations may l^e so minute as to be unrecognizable by the 
naked eye, except for a thrombus projecting from the external 
tubal surface. The tubal abortion in its earliest stage causes 
no marked physical manifestations outside of those symptoms 
which indicate an internal hemorrhage. Later, however, the 
blood-clots in the tube, filling up the sac, produce a large, sausage- 
shaped mass, which may be firm and resistant. The patients 
in whom rupture has occurred may present successive attacks 
of shock and syncope. Thus, a patient bleeds until the blood 
pressure is greatly reduced, a clot forms, plugs the vessel tem- 
porarily, and the circulation is restored. If, however, injudicious 




^m 



Fig. 446. — Ectopic Gestation Sac Ruptured, Showing Fetus. 

efforts are made to revive the patient by hypodermatic injections 
of strychnin, digitalin, or intravenous injection of salt solution, 
the clot is washed or driven out and hemorrhage again recurs, 
with a repetition of the former symptoms. Noble has reported 
cases in which the rupture and hemorrhage have been associated 
with a rather rapid and marked rise of temperature. The 
general rule, however, is that where hemorrhage is marked 
the patient shows a subnormal temperature, as would be ex- 
pected in cases of shock and threatened collapse. The tem- 
perature rarely is elevated until some days after the hemor- 
rhage, and then is not high. The elevation of temperature 
is undoubtedly due to degenerative changes in the collection, 
possibly from the fibrin-ferment, or more likely from partial 



602 . GYNECOLOGY. 

infection by organisms from the intestinal canal. At the time 
of this elevation of temperature the peritoneal exudate is thrown 
out, which forms barriers and confines the blood accumulation 
within the pelvis. The w^atery portions of the blood become 
absorbed, until a more or less distinct and well-defined mass of 
clotted blood is perceived. In extraperitoneal hemorrhage the 
symptoms are much less acute. Shock or collapse is less marked, 
although we still have symptoms which, to a limited degree, 
should lead one to suspect internal hemorrhage. In such a 
case examination will disclose on one side of the pelvis a mass 
which may fill up and distend the broad ligament. The tumor 
may be quite tense and push the uterus to the opposite side. 
The condition differs from tubal disease in that the broad liga- 
ment is distended by it. There has been an absence of recent 
inflammatory trouble, and the patient does not present the 
characteristic symptoms of inflammation. In the intraperi- 
toneal variety the irritation of the accumulated blood causes 
certain reactive symptoms and sometimes the development 
of peritonitis. The temperature becomes elevated, pulse rapid, 
the abdomen tender and sensitive to pressure. But the symp- 
toms are not so acute and severe as in marked inflammation. 
The rupture and internal hemorrhage are usually associated 
with a discharge from the uterus of decidual membrane, either 
as a complete cast of the cavity or in the form of shreds mixed 
with clots. The cast may show the oriflce of the Fallopian 
tubes and internal os. Inquiry should be made with regard 
to this symptom, and, when possible, the discharged material 
should be carefully examined. It is important to differentiate 
it from the decidua thrown off in some forms of dysmenorrhea. 
That of pregnancy is from six to eight millimeters in thick- 
ness, while that of menstruation rarely exceeds two or three 
centimeters in length and is scarcely two millimeters in thick- 
ness, is translucent, is rarely passed entire, and consists of the 
compact layer of the epithelium. When the symptoms have 
been slight and the woman has considered herself the subject 
of an abortion, it is not until the enlarged fetal sac causes a 
suspicion of the continuation of the pregnancy that the patient 
will present herself for examination, and even then she may 
not consult a physician. 

3. Secondary Rupture. — Secondary rupture necessarily fol- 
lows a primary rupture, which, in the majority of cases, has 
taken place in the broad ligament. The rupture has occurred 
in such a way as not to interfere with the vitality of the ovum. 
Retaining its vitality, it enlarges its implantation, and in its 
growth spreads out the broad ligament until the latter is no 
longer able to retain it, when from pressure the thinned wall 



EXTRA-UTERINE PREGNANCY. 603 

finally ruptures and severe hemorrhage takes place into the 
peritoneal cavity. The history of repeated attacks of pain 
and distress, of symptoms of internal hemorrhage, of the en- 
larging abdomen, and, finally, the cutting, agonizing pain 
associated with rupture into the peritoneal cavity should be 
sufiicient data upon which to base the diagnosis of secondary 
rupture. Both in primary and secondary rupture the amount 
of hemorrhage will depend upon its relation to the site of the 
placenta. Where the rupture takes place over the latter, 
the hemorrhage may be very profound and so rapid as to re- 
sult in death of the woman before measures can be instituted 
for her relief. 

4. Continued Growth of the Embryo after Rupture. — As has 
already been seen, this growth may take place into the broad 
ligament, spreading it out, or in those cases in which the em- 
bryo has become reimplanted upon the surface of the perito- 
neum, the ovary, or in a continuation of the tube, the growth 
advancing as it would in ordinary pregnancy. The fetal 
movements are recognized, the enlargement continues, and 
the patient imagines herself normally pregnant. On phy- 
sical examination of such a patient the parts are more dis- 
tinctly defined by bimanual palpation than if the mass were 
situated within the uterus, as there is less structure intervening 
between the fetus and the palpating hand. The recognition 
of the fetal heart sounds is an absolute indication of the ex- 
istence of pregnancy. After the completion of the normal 
term of pregnancy in such a patient ^ the appearance of 
spurious labor, the cessation of fetal movements, and the changes 
which come under observation months later, may greatly 
increase the obscurity of the condition. 

A patient came under my observation who supposed her- 
self pregnant, and who suffered from a bloody discharge, with 
considerable pain, at the end of the second month, which led 
her to think that an abortion had occurred. The supposed 
abortion occurred in February. Her abdomen consequently 
became enlarged, and in the following October she went inta 
labor. Pains continued for tv/o days, and after the move- 
ments ceased her menstrual periods returned. In April, when 
she came under my observation, she presented a tumor as- 
large as in a pregnancy at full term, over which there was dis- 
tinct fluctuation and marked resonance. A thin-walled sac 
was recognized, but there was no sign of a resistant mass. Vag- 
inal examination disclosed behind the uterus a tumor which 
filled Douglas' pouch. The uterus was enlarged and was situ- 
ated directly in front of the tumor. On percussion, there 
was resonance everywhere. No dulness could be distinguished,. 



6Q4 GYNECOLOGY. 

although fluctuation was distinct. The diagnosis was an ectopic 
gestation, with death of the fetus, decomposition in the fetal 
sac, and the formation of gas. This diagnosis was confirmed 
by opening the abdomen and finding posterior to the uterus 
a sac which contained a macerated fetus and a considerable 
quantity of offensive fluid. 

5. Peritonitis. — Peritonitis may take place as a result of 
rupture of the sac, the escape of its contents into the peritoneal 
cavity, the accumulation of blood from a large hemorrhage, 
and its irritation upon the pelvic peritoneum. Unless relief 
is afforded, extensive matting together of the intestines and 
pelvic structures occurs, which will require early operative inter- 
ference for relief. Peritonitis may be produced, also, by the 
death of the fetus and infection of the sac. Its occurrence 
is indicated by pain and tenderness over the abdomen, the 
distention of the belly, assumption of the dorsal position, dis- 
tress during the evacuation of the bladder or movement of 
the bowels. 

6. Suppuration. — Suppuration in an ectopic gestation may 
follow its rupture, so that the contents of such a sac becomes 
sanguinopurulent. Suppuration also takes place in later stages 
of a pregnancy which has gone on to full term; the fetus has 
subsequently become macerated, mummified, or even a lith- 
opedion has formed. Suppuration may take place months or 
even years after the occurrence of a pregnancy, leading to the 
evacuation of the sac or to its rupture into the intestine, the 
bladder, the vagina, or through the abdominal wall. In such a 
case the fragments of the fetus and its bony structure will be 
discharged. Suppuration will be indicated by increased pain 
and distress, by recurring chills, sweating, elevation of tem- 
perature, and the ordinary symptoms associated with sup- 
purative processes. That the suppuration has originated in 
an ectopic gestation will be demonstrated by the previous 
history of the case. This is made absolutely certain when 
the bony fragments of the fetus are discharged. 

552. Differential Diagnosis. — Tubal and uterine pregnancy 
may coexist. Uterine pregnancy may follow tubal, or re- 
peated uterine pregnancies may occur subsequent to the for- 
mation of a lithopedion. Tubal pregnancy may be bilateral. 
Its frequent occurrence in the remaining tube after removal 
of a tubal gestation sac has led some operators to advocate 
the removal of both appendages in every case of tubal gesta- 
tion. Tubal pregnancy may coexist with ovarian and tubo- 
ovarian tumors. In a case I saw with Dr. J. M. Fisher the 
symptoms justified his diagnosis of rupture of a tubal gesta- 
tion sac. From its outline a mass upon the left side of the 



EXTRA-UTERINE PREGNANCY. 605 

pelvis was considered to be a large extraperitoneal hemato- 
cele, which I decided to evacuate by a vaginal incision. A 
large quantity of clotted blood w^as evacuated, above which 
was a smooth cyst, too large to remove through the vagina. 
The ruptured tubal gestation sac was upon the opposite side. 
The removal of the cyst was effected by an abdominal incision. 
The following conditions may be confounded with ectopic 
gestation: first, uterine pregnancy; second, pregnancy in a 
bicornate uterus; third, a retroflexed gravid uterus; fourth, 
spurious pregnancy; fifth, ovarian tumors; sixth, uterine tumors; 







% 



Fig. 447. — Large Ectopic Gestation Sac. 

seventh, intraligamentary tumors; eighth, accumulation of 
feces in the rectum. 

First, uncomplicated uterine pregnancy is generally more 
easily recognized by the change in shape and size of the organ. 
In ectopic gestation the jug-like shape or outline of the fundus 
is wanting. A sac or mass, rather sharply defined, will be found 
in one of the tubes, if rupture has not occurred, and the sub- 
jacent vessels will pulsate more distinctly than upon the oppo- 
site side. After rupture the condition is distinguished by 
more or less severe shock, profound anemia-, and the appear- 
ance of a large mass in the pelvis without a history of previous 
inflammatory phenomena. The introduction of the sound 



606 GYNECOLOGY. 

and the use of the curet to secure decidual tissue have been 
advocated, but are procedures which are not free from danger. 
In possible uterine pregnancy and abortion the danger of in- 
fection must not be overlooked. The investigation for decidua 
may be misleading, as it may have been previously exfoliated. 
The tissue removed by a curet can not be certainly distinguished 
from that which will be caused by inflammation, and the pro- 
cedure endangers the development of septic processes, which 
will complicate a tubal gestation if any exists. 

Second, pregnancy in one horn of a bicornate uterus may 
be impossible to differentiate from a tubo-uterine or an inter- 
stitial pregnancy. Fortunately, the treatment of the two 
conditions is similar, and is almost equally urgent. A tubal 
gestation is situated at a greater distance from the uterus. 

Third, the retro flexed pregnant uterus is "recognized by 
palpation, in which we are able to trace the tumor back from 
the cervix, and the smoothly outlined fundus is capable of 
considerable movement. 

Fourth, careful analysis of the symptoms, associated with 
the accurate consideration of physical signs, will guide to a 
correct diagnosis. It is a grave error to mistake, after the ab- 
domen has been opened, an extraperitoneal pregnancy for 
sarcoma or myoma. 

Fifth, ovarian tumors are usually differentiated by their 
history. It is only when one of these growths has produced 
no symptoms by which its presence could be suspected, and 
is suddenly complicated by an acute attack, during which 
or subsequent to which examination discloses its presence 
more or less fixed in the pelvis, that error is possible. Such 
a train of symptoms is readily produced by twisting of the 
pedicle of a small ovarian or a broad-ligament cyst. A young 
unmarried woman came under my observation with a history 
of having had a severe attack of pain upon the right side, which 
was pronounced appendicitis. While a movable mass could 
be felt above the brim of the pelvis upon the right side, 
there was no indication of inflammatory exudation. Not- 
withstanding the good character of the individual, ectopic 
gestation was regarded as a possibility. An abdominal incision 
disclosed a broad-ligament cyst beyond the ovary, closely 
attached to the outer part of the tube, whose pedicle had twisted, 
causing hemorrhage into the cyst and twisted portion of the 
tube, with the effusion of a large quantity of bloody serum 
free in the peritoneal cavit}^ 

Sixth, when, in an extra-uterine pregnancy, the fetus is 
dead, the fluid portions have been absorbed, and the mass 
is hard and firm, with its sac closelv adherent to the side of the 



EXTRA-UTERINE PREGNANCY. 607 

uterus, the physical signs are frequently insufficient to establish 
the differential diagnosis between it and an intraligamentous 
myoma. 

Seventh, intraligamentary tumors are easily confounded 
with ectopic gestation. Frequently the diagnosis can be deter- 
mined only after abdominal incision. A patient was brought 
to me with the following history: She had been married nine 
years and had never been pregnant ; six weeks before admission 
she was seized with severe pain in the left side, and subsequent 
inflammatory symptoms, which confined her to bed the greater 
portion of the time. A mass, quite resistant, was felt to the 
left and in front of the uterus, which was firmly fixed by ad- 
hesions. The long period of sterility, sudden onset, and more 
or less fixed tumor, not previously recognized, led me to sus- 
pect tubal gestation with intraligamentary rupture. The 
incision, however, disclosed an intraligamentary ovarian cyst 
with thick walls, which had undergone a degenerative pro- 
cess, and which probably explained the sudden onset. 

Not infrequently the diagnosis can be determined only 
by incision, and an ectopic gestation is found when opera- 
tions are performed for other conditions, and the reverse. 

Eighth, careful examination should exclude fecal accumu- 
lation; ordinarily, the latter condition is determined by the 
possibility of indenting the fecal masses. AVhen there is any 
■doubt, an expression of opinion should be withheld until a 
•complete evacuation of the bowels can be secured through 
the employment of an active purgative, supplemented by 
free rectal enemas. 

The differential diagnosis of tubal rupture is often difficult. 
Rupture is simulated by lesions of the abdominal viscera, such 
as perforating ulcers in the stomach, duodenum, small in- 
testine, and vermiform appendix; rupture of a pyosalpinx; 
torsion of the pedicle of a small ovarian cyst; acute intestinal 
obstruction; renal and biliary colic. A case of tubal gestation 
has been brought to operation as a supposed strangulated 
hernia. The diagnosis of tubal rupture can always be rendered 
certain by a puncture through the posterior vaginal fornix, 
when the rupture will be indicated by the discharge of dark- 
colored blood. The vaginal puncture affords," in addition, 
opportunity for the digital exploration of the pelvic viscera. 
Such an investigation permits palpation of the tubes and ovaries 
and the recognition of existing abnormalities. 

The following table, modified by Greig Smith from Web- 
ster, presents in a convenient form a summary of the pathologic 
and clinical features of ectopic gestation: 



608' GYNECOLOGY. 

A. Ampullar. — Gestation beginning in the ampulla of the tube. 

I. Persisting (rarely goes to full term), 
II. Rupture (the usual result): 

1, Into broad ligament: 

(a) Gestation continues there. 

(6) Secondary rupture into peritoneal cavity. 

{c) Gestation terminates: 

{a') By formation of hematoma. 

{b') By suppuration. 

{c') By mummification. 

2. Into peritoneal cavity: 

(a) Gestation continues, the placenta remaining in the tube, the 

fetus and the membranes being in the cavity. 
(6) Gestation terminates: 

(a') The patient dying from hemorrhage or shock. 
(60 By absorption of the mass. 

{c') By mummification or by adipocere or lithopedion forma- 
tion. 
III. Destruction of gestation: 

1. By tubal abortion. 

2. By formation of mole. 

3. By hematosalpinx. 

4. By suppuration. 

5. By absorption after early death. 

B. Interstitial, when the gestation develops in the interstitial portion of 

the tube: 
I. Persisting (the gestation may go on to term). 
II. Rupture: 

1. Into the peritoneal cavity. 

2. Into the uterine cavity. 

3. Into both the peritoneal and uterine cavities. 

4. Between layers of broad ligament. 

III. Destruction of gestation and retrogressive changes in fetus and envelops. 

C. Infundibular, when the gestation is in the outer end of the tube. 

The ovary may form part of the wall of the sac. 

553. Prognosis. — Extra-uterine pregnane}^- at any stage of 
its progress must be regarded as a condition fraught with the 
greatest peril to the individual. It should be regarded as just 
as positive an indication for treatment as would be the presence 
of malignant disease. If discovered before the rupture of the 
sac, the patient is in danger from hemorrhage. The longer 
the condition progresses, the more grave is the peril. After 
rupture, with death of the fetus, the patient is not free from danger, 
as the collection of blood — the hematocele — may become infected, 
from its proximity to the hollow viscera, and cause the formation 
of an abscess or the development of pyemic symptoms. If the 
fetus survives the rupture, its subsequent development only in- 
creases the danger. A secondary rupture, with escape of the sac 
contents into the peritoneal cavity, or the frightful hemorrhages 
which result in some conditions, may prove immediately fatal. 
The woman goes on to full term ; the fetus dies, then undergoes 
retrogressive processes, which may at any time, even after years 
of quiescence, become infected, resulting in the formation of ab- 
scesses, perforation of viscera, and escape of the contents of the 



EXTRA-UTERIXE PREGNANCY. 609 

sac. As the nutrition of the fetus in the majority of cases is de- 
fective, from unfavorable implantation of the placenta, frequently 
from pressure upon it, the fetus is generally imperfectly devel- 
oped, often undersized, suffering from hydrocephalus, spina 
bifida, club-foot, ' and other deformities. The preservation of 
the life of such an individual should not be considered when 
it is recognized that the life of the mother is constantly in peril. 
Furthermore, the fact that, even under the most favorable 
circumstances, the chances for the fetus are very greatly de- 
creased, and that, even when delivered alive, its duration of 
life is short, should be taken into account. The statistics of 
Dunning, hoAvever, indicate that an operation for the dehver}^ of 
the child during life, when viable, is more favorable for the life 
of the mother than is the delay of the operation until after the 
death of the fetus. 

554. Treatment. — In a condition replete with such dangers 
as that of ectopic gestation it does not seem the province of 
the physician to practise any other method than one which 
will afford the greatest certainty of relief and which can be 
accomplished with the least danger. This, in our judgment, is 
through surgical manipulation; but, as other methods of treat- 
ment have been advocated, before entering upon the considera- 
tion of extirpation we will consider the substitutes. The sub- 
stitute methods recognized are evacuation of the liquor amnii, 
injection of poisonous substances, elytrotomy, and the ap- 
plication of the electric current. 

The evacuation of the liquor amnii was advocated by Simp- 
son in 1864. He treated a case by puncturing the cyst through 
the vagina without killing the child, and the mother died in 
three days. Braxton Hicks tried a similar method in 1865, 
which killed the child, but the mother died of hemorrhage. 
Greenhalgh, in 1867, had a successful case. James, of Phil- 
adelphia, in 1867, had a successful case after much tribulation. 
This plan of treatment, owing to the great mortality, has been 
generally abandoned. 

The injection of poisonous materials into the fetus and 
its enveloping fluids was advocated by Joulin in 1863. Morphin 
is the drug most frequently used. Other remedies, such as 
strychnin and ergotin, have been similarly employed. In- 
unctions of mercury, the administration of potassium iodid, and 
repeated bleeding have been advocated, but it is difficult to explain 
why. The injection of morphin with a hypodermatic syringe is 
practised before the fifth month. Two injections are usually 
given, containing J of a grain each, at an interval of from eight to 
fifteen days. The treatment may result in severe hemorrhage, 
septicemia, and perforation of an intestinal loop, so that, while- 
39 



610 GYNECOLOGY. 

apparently a simple procedure, it is attended with greater 
danger than an abdominal operation. 

Elytrotomy, or the removal of the fetus and its contents 
through a vaginal incision, was instituted as early as 1817 by 
Dr. King, of Georgia. This operation, which has been lately 
revived, is not by any means a new one. In the discussion of 
hematocele vaginal incision has been advocated as a justifiable 
method of procedure when the condition has become chronic; 
in other words, some time after the hemorrhage has taken 
place, when the vessels are occluded and the fetus is more than 
likely to be dead. In such cases vaginal incision affords an 
opportunity for clearing away the debris without subjecting 
the patient to so serious an operation as would be that through 
the abdominal wall. But before rupture, or immediately 
following rupture, in order to arrest the hemorrhage, the ab- 
dominal incision should be preferred. When the patient has 
reached full term and the death of the fetus has occurred, but 
as yet without the appearance of suppuration, the vaginal pro- 
cedure may be chosen: (i) When the fetus presents the head, 
breech, or feet, so that it can be extracted without altering 
its position; (2) when it is certain, from the thinness of the 
structures separating the presenting part from the. vaginal 
canal, that the placenta is not situated over this part of the 
sac, and we are not absolutely certain that the placenta may 
not be inserted on the anterior abdominal wall. If it is neces- 
sary to turn the child in order to deliver it, the vaginal pro- 
cedure should not be considered. Robertson advocates dividing 
the perineum, septum of the vagina, and rectum, but this is an 
unnecessarily severe proceeding. 

The application of electricity for the destruction of the 
fetus has been practised since 1853. There is a difference of 
opinion, however, among electrotherapeutists as to the greater 
value of the faradic and galvanic currents, each having its 
advocates. This procedure is preferable to all those which 
have been named, but is advisable only in the earlier months 
of pregnancy. In the early stages we must take into con- 
sideration the fact that the diagnosis is not always certain. 
Without doubt, many of the cases reported to have been cured 
by electricity were cases which had undergone rupture, and 
in which the tubal mole or embryo had escaped and lost its 
vitality, and the electric treatment has possibly served to ex- 
pedite the absorption of the exudation — an absorption which 
would have taken place had electricity not been applied. Many 
cases in which electricity has been applied were undoubtedly 
cases of mistaken diagnosis. It is true that advanced methods 
of examination will more certainlv differentiate the condition, 



EXTRA-UTERINE PREGNANCY. 611 

but the violence required to accomplish this will greatly en- 
danger the rupture of the fetal sac. The application of electric- 
ity has occasionally been found to intensify the contraction 
of the muscle-fiber of the tube and to result in rupture and 
severe hemorrha,ge. When the death of the fetus occurs the 
danger does not cease, and we will frequently find the placenta 
continuing to grow, or rupture may follow,, associated with 
severe hemorrhage and later with septicemia. In the applica- 
tion of the current one pole of the battery, generally the neg- 
ative, is applied through either the rectum or the vagina in 
the neighborhood of the ovum. The other pole or a large 
electrode is applied to the abdominal wall directly over the 
sac and an inch or more above Poupart's ligament. The cur- 
rent is used for from five to ten minutes, increasing it as the 
sensitiveness of the patient will permit. When necessary, 
the application should be repeated. The practice of this pro- 
cedure is of doubtful utility, and, as has already been men- 
tioned, it is not without danger. It temporizes with a condition 
which menaces life and may excite severe tubal contractions 
which often result in rupture with subsequent hemorrhage. 

The risks and difficulties of operative treatment will largely 
depend upon the stage of gestation and the condition of the 
placenta and gestation sac. The surgeon, to be properly prepared 
to meet all emergencies, should consider the following: (i) 
The measures to be employed before primary rupture or abor- 
tion; (2) the measures required at the time of primary rupture; 
(3) what shall be done for the patient coming under obser- 
vation subsequent to rupture — (a) with intraperitoneal hemor- 
rhage; (b) with extraperitoneal hemorrhage; (4) the niethod 
of treatment advisable in advanced growth of the embryo — 
(a) the child alive; (b) the child dead, mummified, or reduced 
to a lithopedion; (c) following decomposition of the fetus and 
suppuration of the sac. 

I. The Measures to be Employed before Primary Rupture or 
Abortion. — Cases in which opportunity is afforded to operate 
prior to the rupture of the sac are more frequent than form- 
erly, owing to our improved m.ethods of diagnosis and to the 
greater significance given to disorders accompanying pregnancy. 
Too frequently, still, the disorder will be overlooked until the 
danger-signal of rupture appears. When the symptoms pres- 
ent make it evident that an ectopic gestation exists or is ex- 
tremely probable, the patient should be subjected to operation 
at the earliest possible moment. The danger arising from 
rupture is so great that the patient should be considered in 
peril of her life until the condition is corrected. The abdominal 
incision is the preferable procedure, inasmuch as it affords a 



612 . GYNECOLOGY. 

better opportunity to explore the field, to manage adhesions, 
and to secure bleeding vessels. The removal of the entire 
sac rarely affords any special difficulty. In a tubo-ovarian 
pregnancy it is possible that a knuckle of intestine may have 
become adherent to the sac. In such cases the removal of 
the latter must be carefully managed, because the changes 
which take place in the adherent intestine render it easily torn. 
Failure to recognize this possibility in my own experience led 
to the necessity of resecting a knuckle of intestine for an ex^ 
tensive tear. The patient, however, fortunately recovered. 

2. The Measures Required at the Time of Primary Rupture. — 
Unfortunately, the attention of the physician is much more 
frequently directed to the occurrence of primary rupture or 
abortion than to the existence of an ectopic gestation prior 
to this event. Very frequently the efforts employed to 
arrive at a correct diagnosis may be the means of the pro- 
duction of this catastrophe. Therefore, I would again em- 
phasize the importance of delicate manipulation in a case of 
suspected ectopic gestation. Indeed, prior to the careful 
examination of a patient in whom an extra-uterine pregnancy 
is suspected it would be well to have ample provision for re- 
sort to immediate surgical firocedure, in the event of collapse 
or rupture of the ectopic sac. Should the disaster occur during 
an examination, or the physician be called upon to attend a. 
case in which rupture had recently occurred, he should endeavor 
to keep the patient perfectly quiet and free from annoyance, 
with her clothing loosened. The foot of her bed should be 
elevated and a hypodermatic injection of morphin should be 
administered with a view not only to quiet the pain, but to 
lessen the nerve irritability and restlessness. An ice-bag should 
be applied over the abdomen, and immediate preparations 
made for opening the abdomen, in order to secure the bleeding 
vessel. The patient should be placed under the influence 
of an anesthetic. If the operator is at all in doubt as to whether 
the condition has resulted from an internal hemorrhage, he may 
confirm his suspicions and satisfy all doubts by cleansing the 
vagina and making a puncture through the posterior fornix, 
which will permit the recognition of the escaping blood. In- 
deed, through such a puncture the tubes may be examined 
and the presence of the sac recognized. Moreover, a skilful 
operator may be able to secure the bleeding vessels through 
the vaginal incision. Indeed, it has been advocated that the 
ruptured tube should be brought down, the surfaces cleansed, 
and sutures so introduced as to control the bleeding vessel 
and close the opening, leaving the tube in place. Such a plan 
of procedure, however, is inadvisable. The fact that the caliber- 



EXTRA-UTERINE PREGNANCY. 613 

of the tube is so obstructed as to have caused an ectopic preg- 
nancy would indicate that its retention must necessarily subject 
the patient to the danger of a recurrence of the condition. The 
abdomen opened, the bleeding vessel secured', with aseptic pre- 
cautions, no grdat effort need be made to free the peritoneal 
cavity of blood, for, if the patient is kept under proper regimen, 
the blood is quickly absorbed and serves in some degree to 
sustain and support her. The absolute indication at this stage 
is to arrest the hemorrhage, and this is most effectively accom- 
plished through an abdominal incision. As soon as the abdominal 
incision is made there will be a gush of blood. The pelvis 
will be found more or less occupied with blood-clot ; do not stop 
to turn out the clots, but proceed through the clotted blood 
to the fundus of the uterus and along either tube to discover 
the sac. The site of the gestation is recognized as a soft, boggy 
enlargement of varying size and consistency, according to 
whether the ovum is, or is not, m situ. The sac is brought up 
and examined for the rent. A¥hen the hemorrhage is marked, 
the pedicle is at once secured with pedicle forceps until the 
cavity can be cleansed and ligatures applied. After ligation 
the sac is cut away. If the patient is very profoundly anemic, 
no time should be lost by attending to the toilet of the abdo- 
men, but it should be simply irrigated with normal salt solution 
to carry away the principal clots. 

3. The treatment of the patient subsequent to rupture — (a) 
with intraperitoneal hemorrhage. The patient, having rallied 
from the shock, will in very many cases recover without opera- 
tive interference by keeping her perfectly quiet, promoting 
drainage through the intestinal canal by frequent purgation, 
and limiting the amount of food and drink that is given. She 
is thus obliged to live upon her tissues, which will promote the 
absorption of even a large collection. As we have already 
seen, the tube which has been the seat of an abortion will gener- 
ally be found distended with clots, and the same material will 
fill up the retro-uterine pouch. The convalescence of the patient 
will generally be enhanced by the removal of the tube and the 
clotted blood. This is particularly true when the tube is the 
seat of a perforation from the villi, for frightful hemorrhage 
may be found, and, besides, under such conditions it is likely 
to continue. Even when the hemorrhage arises as a result 
of rupture, we are not certain that the clot which plugs the 
vessels may not be loosened and a recurrence of bleeding follow. 
In spite of every precaution that may be observed it is not 
infrequently found that a collection of blood in the peritoneal 
cavity becomes infected from its proximity to the intestine, 
and thus a suppurative process is engendered which prolongs 



614 GYNECOLOGY. 

the patient's convalescence. Even should this not occur, 
the blood-clot, becoming organized, gives rise to thickening, 
extensive adhesions, and more or less crippling of the function 
of the pelvic organs for the remainder of the patient's life. 
If the patient comes under observation some days subsequent 
to the evident rupture, thus affording sufficient time for the 
vessels to become occluded by clots, and with an accumulation 
of blood in the pelvis, which frequently is walled off by plastic 
exudate from the general peritoneal cavity, the preferable 
plan of procedure would be to make a free incision into the 
vault of the vagina. Two fingers should then be introduced 
through this opening, the clots broken up and evacuated, the 
cavity thoroughly irrigated with normal salt solution and 
packed w4th iodoform gauze. The tube may frequently be 
brought down and secured by ligature or clamp between the 
seat of rupture and the uterus, and the mass be thus removed. 
This is particularly true when the tube is occupied by a large 
blood-clot. When the tube is situated high up in the side of 
the pelvis or the lower part of the abdomen, and in a position 
not readily accessible through the vagina, the abdominal incision 
is preferable, as it affords a better opportunity to inspect the 
condition of the pelvic organs, to remove the occluded tube, 
and, if necessary, the associated ovary. It has been urged 
that where one tube has been the seat of an ectopic gestation 
which has ruptured and led to operative interference, the other 
tube should likewise be removed in order to prevent the possible 
occurrence of an ectopic gestation within it. The many cases 
in which a normal intra-uterine pregnancy has followed a tubal 
pregnancy would render such advice unwise. While numerous 
cases are recorded in which an operation for the removal of 
an ectopic gestation has been followed by the occurrence of 
gestation in the remaining tube, this, however, is not the rule, 
and it would be just as logical to forbid matrimony because an 
occasional marriage is unfortunate. 

(b) Extraperitoneal hemorrhage is a result of rupture of 
the tube betw^een the folds of the broad ligament. A hemato- 
cele is thus produced which is situated in the cellular tissue 
between the layers of the peritoneum. The amount of hemor- 
rhage is necessarily limited by the size of the vessel opened, 
the blood pressure, and the distensibility of the structure into 
which the hemorrhage has occurred. Where the collection 
is small, it may be sufficient to treat the patient expectantly, 
watch her progress, and trust to nature to absorb the exudate. 
Even in this condition it should not be forgotten that in rare 
cases the embryo may survive the accident and continue to 
grow. The continuation of the growth of the fetus presents 



EXTRA-UTERINE PREGNANCY. 615 

additional and more serious problems. Prior to the fourth 
month the embryo, tube, ovary, and adjacent portion of the 
broad ligament, including the placenta, can generally be re- 
moved. Subsequent to this period, . however, the placenta 
may have attained such a size as to render its removal difficult. 
Not infrequently the life of the patient is endangered by a 
subsequent rupture. The placenta extends upon the pelvic 
surface, covering over and surrounding the vessels and the 
ureter. Moreover, the intestines may aid in forming the sac 
wall of the developing embryo and a condition result which 
would render any operative interference exceedingly serious. 
Where the patient shows marked symptoms of internal hemor- 
rhage and an examination reveals a collection of large size, 
an immediate operation is preferable, for the depressed con- 
dition of the patient increases the danger of infection of the 
effused blood from the walls of the adjacent intestine. When 
infection enters the sac, suppuration will follow. This, of 
course, greatly endangers the life of the patient. Early inter- 
ference with such a collection is preferably made through the 
abdomen, for the reason that it affords a better opportunity 
of exposing and securing the bleeding vessel. Having opened 
the abdomen, the peritoneal cavity so far as possible should 
be carefully walled off with a large quantity of gauze, the blood- 
clots evacuated, and the bleeding vessels searched for and 
secured. If the blood collection has been a large one and the 
pelvis is covered with adherent blood-clot, an opening should 
be made into the vagina, through which the end of a piece 
of gauze sufficient to fill the cavity should be carried. When 
the collection has been extraperitoneal, the abdomen can be 
walled off with gauze before the broad ligament is opened, 
the clots should be turned out; the bleeding vessel secured; the 
cavity packed with gauze, the end of which has been carried 
through an opening in the vagina, thus allowing the peritoneal 
wound to be closed. Care must be exercised, however, in this 
procedure not to injure the uterine artery or the ureter. 

4. The method of treatment advisable in advanced growth 
of the embryo — (a) the child alive. From the fourth month 
to the completion of pregnancy the existence of a quick placenta 
presents a condition which is generally regarded as the most 
dangerous in the whole realm of surgery. The sac has ruptured, 
the placenta has formed new and more extended attachments. 
While the condition of the patient can not be considered other- 
wise than grave, the immediate danger is not so great but that 
we can afford to wait until a later stage of the pregnancy for 
interference and thus give the fetus a chance for its life. The 
existence of the live placenta and the profound hemorrhage 



616 GYNECOLOGY. 

which results from any effort at its removal have led many oper- 
ators to question the advisability of any operative procedure while 
the child is alive. Some have advocated securing the death of 
the child by injecting into its bod}^ poisonous materials, such 
as morphin, or, when near the completion of the pregnancy, 
awaiting its death. They have justified this course of action 
by the assertion that in the great majority of cases the product 
of ectopic gestation is puny, ill developed, and often malformed, 
and that even when it survives extraction it usually lives but 
a few weeks, or at most months. Therefore they claim that 
the life of the mother should not be endangered to insure the 
life of a defective child. Experience, however, has disclosed 
that the extra-uterine fetus may be well developed, and when 
it is evident that the mother- can be saved only by operative 
procedure, it seems cowardice that this should not be employed 
at such a stage as will give the other being an opportunity 
for continued existence. Fortunately, the investigations of 
Dunning have demonstrated that the maternal chances are 
enhanced by operation during fetal life. The recognition 
of extra-uterine pregnancy, then, should lead to the prepara- 
tion for operation at a certain definite time prior to the com- 
pletion of the gestation, preferably at about eight and one-half 
months. In resorting to operative procedure we must consider 
it from two additional standpoints: (i) As to the treatment of 
the sac; (2) the method of disposition of the placenta. The 
sac is composed of remnants of the expanded tube or of the 
broad ligament, thickened and in parts expanded. In some 
places coils of intestine or the adherent omentum also enter 
into its formation. The removal of the sac, consequently, 
is fraught with danger, not only to the adjacent large blood- 
vessels and ureters, but to the abdominal viscera in general. 
When the pregnancy has passed the fifth month with ample 
evidence of a living child, we would advise that interference 
be postponed until after the eighth month. It should be under- 
taken, however, not later than at eight and one-half months, 
in order to afford the fetus the best chance for its life. 
The operator is compelled to adapt his procedure to the con-, 
dition immediately confronting him. The position of the 
fetus has been recognized and carefully outlined. In the major- 
ity of cases the median incision affords the best opportunity 
for the delivery of the fetus and the management of the sac 
and placenta. Having entered the peritoneal cavity, the 
sac is carefully examined and efforts made to avoid injuring 
the placenta. Where it is situated in front, we should endeavor 
to open the sac on one side. After opening the sac the most 
available part of the fetus is seized and delivered quickly. The 
cord is clamped with two hemostats and cut between them. 



EXTRA-UTERINE PREGNANCY. 617 

The fetus is then removed and given to an attendant to be 
cared for. We now come to the decision of the question we 
have already mentioned, namely, the management of the sac 
and the disposition of the placenta: (i) The sac, as already 
mentioned, is composed of remnants of the distended tube 
or the broad ligament, thickened and in parts expanded. In 
other places coils of intestine or portions of the adherent omen- 
tum assist in forming it. The removal of the sac, consequently, 
is associated with great danger, not only to the adjacent large 
blood-vessels, but to the viscera and ureters. The ideal plan, 
where possible, is to follow the delivery of the fetus by the re- 
moval of the sac, including the placenta; where the removal of 
the sac can not be safely accomplished, the operator should 
stitch its edges to the skin margins of the abdominal w^ound. In 
well-advanced pregnancy we may possibly be able to push the 
peritoneum from the anterior abdominal wall and to penetrate 
the sac without opening the peritoneal cavity, but the chief dif- 
ficulty would be to determine — (2) how we shall manage the pla- 
centa. The method employed w411 entirely depend upon its situa- 
tion. Its management is most promising when situated in the 
pelvis below the fetus. When above the fetus, the placenta may 
be injured and result in furious bleeding or, indeed, even death 
of the patient. Even prompt seizure and ligation of the uterine 
side of the sac may fail to arrest the bleeding. The abdominal 
aorta may then be compressed, the cavity packed with sponges, 
and an application made of perchlorid or persulphate of iron. 
The danger of bleeding has frequently induced surgeons to 
leave the placenta and allow it to slough away, employing 
proper measures for securing external drainage. When the 
removal of the placenta can be accomplished without too much 
risk, it should be done. In addition to avoiding the placenta 
in opening the fetal sac, we should exercise the precaution 
to prevent discharge of the amniotic contents into the peri- 
toneal cavity. After delivery of the fetus the operation is com- 
pleted in one of three ways: (i) The extirpation of the entire 
sac; (2) the removal of the placenta without the sac; (3) the 
retention of the placenta and the sac. 

1. Whenever it can be safely accomplished, the entire sac 
should be removed. By this method the operation is more 
complete and convalescence is more likely to be insured. This 
can be accomplished whenever we can construct a pedicle and 
the sac wall is made up of tissue that can without disadvantage 
be removed. The pedicle may be narrow or broad, as in an 
ovarian cyst. 

2. Extirpation of the Placenta with the Sac Remaining. — The 
placenta should be removed whenever it can be peeled out 
without hemorrhage, or when it is so situated that the vessels 



618 GYNECOLOGY. 

supplying it can be securely ligated and the mass " removed, 
or when its position is such that effective control of hemor- 
rhage can be accomplished by tampons of iodoform gauze. 
After removal of the placenta the gauze may be removed and 
replaced by a large drain. 

3. The Retention of the Placenta and Sac. — When the pla- 
centa is firmly attached or it is evident that its detachment 
would result in dangerous hemorrhage, it should not be dis- 
turbed. The operator should exercise the greatest care in 
the management of the live placenta, as the hemorrhage in 
such cases is frightful and exceedingly difficult to control. 
Where the placenta is partially detached, it may be necessary 
to proceed with its removal. This should be accomplished 
quickly, making firm pressure over the parts with iodoform 
gauze. If the attachment is of such a character as will permit, 
the parts should be quilted together by a ligature which is 
tied firmly around the base of the placenta. Where it is neces- 
sary to retain the placenta and the sac, one of the following 
methods can be practised : The sac can be fixed to the abdominal 
wall and the cavity drained, or the opening in the sac can be 
closed, covering over the placenta and shutting off the latter 
from the peritoneal cavity. In such cases the cord should 
be cut off close to the placenta, after previous ligation with 
chromic catgut, or the electro -angiotribe can be employed. 
This instrument appeals to me as an efficient means of con- 
trolling hemorrhage and insuring the removal of a portion 
of the placenta. To accomplish this, it will require a modifica- 
tion of the angiotribes at present in use, employing one with 
a more flattened surface, thus allowing a good portion of the 
placenta to be subjected to the slow action of heat. The pla- 
centa and sac should be closed and returned to the peritoneal 
cavity only when we have been able to secure absolute and 
rigorous antisepsis. The presence of a single microbe may 
lead to putrefaction of the placenta and suppuration. The 
disadvantages of the retention of the placenta are that its 
separation and discharge are tedious and present continuous 
risks of septicemia and peritonitis. Fecal fistula may form. 
These risks are decreased by irrigation of the sac, by the ligation 
of the cord close to the placenta without disturbing the latter, 
by carefully sponging the cavity, and then, as has been sug- 
gested, by hermetically closing it. Even though we are able 
to exclude the germs from the cavity, it must be remembered 
there is danger of their entrance through adhesions to the in- 
testines. Intestinal micro-organisms may gain access to the 
placenta and produce decomposition. The following rules have 
been formulated by Sutton: (i) When the placenta is situated 
above the fetus, attempt its removal; (2) if the placenta has 



EXTRA-UTERINE PREGNANCY. 619 

become partially detached during the course of the operation, 
no choice is left but its removal; (3) the placenta below the 
fetus can be left; (4) if the placenta is left, the sac closed, 
and subsequently symptoms of suppuration occur, the wound 
must be at once laid open and the placenta removed. 

(6) The Child Dead, Mummified, or Reduced to a Lithopedion. 
— The death of the child at any stage results in very early arrest 
of the circulation in the placenta. The continuation of the 
growth of the placenta after the death of the fetus has been 
considered as a possibility, but this is very improbable. The 
placenta does not decompose, but undergoes slow and complete 
atrophy. The vessels in the maternal portion atrophy and dis- 
appear. This, consequently, leaves much less of the placental 
structure than would be found in an extra-uterine pregnancy. 
The absorption of the placenta continues until, in those cases 
in which the lithopedion is formed, the placenta is found to 
be entirely absent. Should the patient come under observation 
when the history would lead us to suspect that the fetus has 
but recently perished, it would be wise to postpone operation 
a few weeks later, when arrest of the circulation in the pla- 
centa may become complete. The sac is exposed by the ab- 
dominal incision, the general peritoneal cavity is well pro- 
tected by gauze packing, and care exercised that the contents 
of the sac shall be removed without soiling the peritoneum. 
The escape of the contents into the peritoneal cavity should 
be prevented by the employment of an aspirator and the 
sac should be carefully guarded by sponge packing before 
it is opened. The fetus is withdrawn and the sac then 
examined, with a view to its removal, if possible. Where 
the condition will admit, the entire sac, with the enclosed 
placenta, should be removed. If knuckles of intestines are 
adherent to the sac, the greatest care should be exercised in 
their separation, in order to avoid inflicting injury to them. 
Where the adhesion is very firm, the separation should be made 
at the expense of the sac wall, leaving a portion of it attached 
to the intestine. When a large portion of the intestine enters 
into the formation of the sac wall, the removal of the sac will 
not be feasible. In such cases the placenta should be peeled 
out, the cavity thoroughly sponged with carbolic acid and 
afterward with alcohol, dried, packed with gauze, and its edges 
stitched to the abdominal wound. Where the sac is dependent 
and in close approximation to Douglas' pouch, an opening 
should be made through its base into the vagina, through which 
drainage maybe effected and the upper part of the sac closed. 
The vaginal drainage of the sac should be employed whenever 
possible, as the drainage is from the most dependent portion 
and the convalescence of the patient is much shorter and 



620 GYNECOLOGY. 

the dangers of subsequent ventral hernia greatly decreased. 
Following the death of the fetus marked changes occur. 
The fetus itself may become mummified, its watery portions 
absorbed, forming a flattened mass. Or, again, the entire 
fetus undergoes a substitution of fat for its original structures, 
forming a lardaceous condition; or, again, we may have the 
fetus and its sac filled up with calcareous deposit, causing a 
rather dense, hardened mass. Some of these conditions may 
continue for years. A lithopedion has been found in a woman 
of ninety. Their presence, however, always predisposes to 
infection, which may result in suppuration, with subsequent 
discharge of particles of the calcified mass. Wherever pos- 
sible, the entire mass should be removed. Wherever it is rec- 
ognized, after an abdominal incision, that the mass has formed 
extensive adhesions to the intestines and other structures 
of such a character as to preclude the probability of successful 
removal, the sac should be opened, its contents so far as pos- 
sible removed, the sac wall stitched closely to the abdominal 
wound, and its cavity packed with gauze. The removal of 
the fetus and the drainage of the sac result in its complete 
obliteration and the restoration of the patient to health. 

(c) Following Decomposition of the Fetus and Suppuration 
of the Sac. — Decomposition of the fetus and suppuration of 
the sac are indicated by symptoms of inflammation, the sac 
becoming tender to pressure with evidence of localized peri- 
tonitis. The temperature of the patient will be elevated; pos- 
sibly recurring chills, night-sweats, progressive emaciation, 
and symptoms of low continued fever will be manifest. Lique- 
faction of the sac by pus-formation causes thinning and even 
rupture of its walls, with the escape of its contents into the 
peritoneal cavity, the bladder, the intestine, the vagina, or 
through the abdominal w^alls. The rupture results in the for- 
mation of a sinus, through which often will be found passing 
fragments of small fetal bones. The existence of suppuration 
should be considered an indication for immediate operation. 
To open the sac without entering the peritoneal cavity is, of 
course, more satisfactory, and this occasionally can be accom- 
plished. If the adhesions between the peritoneal surfaces are 
not extensive, the opening may be a small one, and by gauze 
packing and other means the adhesions may be extended. 
Where parietal adhesions do not occur, the sac should be opened 
and its contents thoroughly evacuated, but the peritoneal 
cavity must be thoroughly protected from soiling by gauze 
packing. Every fragment of bone should be removed, for 
otherwise the obliteration of the sac will not take place and 
suppuration will continue as long as the irritation remains. 
The cavity of the sac should be thoroughly packed with iodo- 



GENITAL TUMORS. 



621 



form gauze and the sac itself be stitched to the skin edges. 
During the convalescence the cavity should be frequently irri- 
gated with antiseptic fluids. We may sometimes be able, es- 
pecially where the opening has taken place through the 
abdominal wall, to dilate the sinus and empty the sac with- 
out opening into the general peritoneal cavity. This method 
of procedure can be effectually employed in the opening 
through the abdominal wall and the vagina, but openings into 
the bladder or intestine will require abdominal operation. How- 
ever, efforts should be made to remove the sac, if possible, 
and to close the intestinal or vesical openings. 



GENITAL TUMORS. 

555. Definition. — In the broad sense of the term any unusual 
swelling or protuberance of a part can be called a tumor, but the 
designation is properly restricted to a new-growth which is inde- 
pendent of the results or productive of inflammation. Such a 
growth is distinctly circumscribed, has a marked course, can be 
definitely differentiated, and is associated Avith febrile symptoms 
only when degenerative changes exist. 

556. Classification. — Tumors of the genitalia, like those 
occurring in other portions of the body, are divided clinically 
into the benign and malignant; pathologically into neoplasms 
and cysts, and histologically into those which originate in adult 
or in embryonic tissues. The following table, prepared for me 
by Dr. P. B. Bland, presents the subject in a readily compre- 
hensive form : 









f 


Adult connective tissue < 


Fibroma 
Myoma 
Fibromyoma 
Fibro-adenoma 
Angioma " 






^ Solid 


1 
i 




Lipoma 
Myxoma 
Chondroma 
Osteoma 


Benign 






! 

I 

[ 
I 


Adult epithelial tissue 
Retention 


Neuroma 

Papilloma 

Adenoma 






. Cystic 


Congenital ^ Teratoma^ 

[ Vaginal cysts 




Malignant 




0^ 


Embr} 


'onic epithelial tissue 


Carcinoma 
Chorio-epithelioma 
malignum 






Embr> 


'onic connective tissue < 


Sarcoma 
Endothelioma 



622 GYNECOLOGY. 

When we come to analyze the arrangement into groups of 
these growths, we find that any arrangement must be more or 
less arbitrary, and the transition from one form to another is so 
subtle as to make the assignment of some growths very difficult 
and uncertain. The definition into benign and malignant is of 
classic origin and necessarily is of great importance. A benign 
tumor may be defined as one which in the course of its develop- 
ment inclines to remain local or confined to the structures in 
which it originated. It de\'elops from adult tissue, in its prog- 
ress is not usually destructive to life, and displays no dis- 
position to metastasis nor to recur when removed. The malig- 
nant tumor, on the contrary, is supposed to have its nidus in 
embryonic tissue, gradually breaks down its original barriers, 
invades the surrounding structures, extends by metastasis until 
the entire organism may become infected, and displays a marked 
tendency to recur after surgical intervention. 

The study of the structure of gro^^-ths shows a marked 
difference in the cellular tissue of the two classes, each having 
well-defined tissue changes which render them recognizable, 
and from which the future progress may be predicated. 

In the differential diagnosis it is often difficult to draw the 
line and assert that the benign terminates here and the malignant 
begins there. In some of the uterine and ovarian growths, par- 
ticularly the glandular varieties, we are forced to rely upon the 
life history of the growth in order to determine its proper classi- 
fication. Notable examples are the glandular and malignant 
adenomata of the uterus and the papillomata of the ovary. 

VULVA, VAGINA, AND BLADDER. 

557. Characteristics of Benign Neoplasms. — The benign 
growths have been divided into solid and cystic, and the former, 
from their structure, into the connective-tissue and the epithelial 
tumors. The connective-tissue growths predominate among the 
benign, and while they may be found in all the tissues of the geni- 
talia, they to the greatest degree characterize those springing from 
the uterine parenchyma and are known as the myomata or fibro- 
myomata, according as the muscular or connective tissue pre- 
dominates, or the fibromyomata in a combination of the two. 
Cystic tumors are those which consist of the envelope, sheath, or 
sac containing thin serum, blood, pus, mucin, sebaceous material, 
parasites, hair, cartilage, or bone. These tumors have their 
origin in the ovaries, broad ligaments, vulva, and vagina, in con- 
genital remains, as the Wolffian bodies, the parovarian and 
remnants of the ducts of Gartner, and the Mullerian ducts. 
Cystic growths of the ovary present considerable difficulty in 



GENITAL TUMORS. 623 

classification, inasmuch as twenty per cent, of them prove to be 
malignant. Even careful microscopic examination of the growth 
will not always enable it to be properly classified, because a 
malignant nodule or portion may be engrafted upon what other- 
wise seems a benign growth, and may be so situated that it can 
readily escape observation, for the examiner would be entirely 
unable to subject the parts of a large gro\^rth to such an investi- 
gation. Certain of these gro\\i:hs — ^the papillomatous variety — 
show a disposition to grow through the enveloping sheath or 
cyst wall, and when it is ruptured, their contents are infected or 
become implanted upon the peritoneal surface, causing a low 
grade of peritonitis and an extensive ascites. Such behavior at 
once answers to the description of malignant disease, but experi- 
ence reveals that in the majority of cases the removal of the origi- 
nal source of infection, the ovarian growth, produces atrophy and 
disappearance of the secondary infection of the peritoneum. 
In many of these growths the surgeon is compelled to deter- 
mine the final diagnosis between benignancy and malignancy by 
the subsequent clinical history of the patient. In discussing 
specific gro\A^hs, comparison can more readily be made by con- 
sidering separately the tumors, benign or malignant, which are 
prone to occur in each portion of the tract. 

558. Unclassified. — In the former editions I discussed some 
conditions under genital tumors, using the term in its unre- 
stricted sense, which I will now consider separately. These condi- 
tions are hernia, hydrocele, varicose veins of the vulva, edema, 
elephantiasis, and urethral caruncle. 

559. Hernias. — The gaseous cysts are hernias which present 
in the vulva in tw^o varieties — the anterior labial or inguinal and 
the posterior labial. The anterior labial hernia is analogous to 
the scrotal hernia in the male. It is formed by a portion of 
intestine or omentum descending through the inguinal canal and 
distending the large labium. (Fig. 448.) This form of hernia is 
comparatively rare in women. Femoral hernia is much more 
frequent in the female. In the latter the hernial sac emerges 
below Poupart's ligament and makes its exit as a lump in the 
groin, which, as it increases in size, pushes up over the ligament. 
In the sac of an inguinal hernia has been found an ovary and 
tube and even the fundus of the uterus. Instances have been 
recorded of an ovarian cyst or a tubal gestation complicating 
such a hernia. The posterior labial hernia (Fig. 449) is formed 
by the intestine driving the peritoneum through the pelvic 
aponeurosis and the levator ani muscle. The sac appears at the 
side of or projects through the vulvar orifice. Labial hernia 
may sometimes be difficult to difterentiate from hydrocele or a 
fatty tumor of the labium. A double hernia with an ovary in 



624 



GYNECOLOGY. 



each labium associated with a large penis-like clitoris may cause 
some doubt as to the sex of the individual. 

560. Hydrocele. — A well-formed serous cyst which is con- 
tinuous is sometimes situated in one or the other labium ma jus, 
or when the canal of Nuck is patulous it may, b}^ slight pressure, be 
emptied back into the peritoneal cavity to recur as soon as the 
patient assumes the upright. This tumor is known as hydrocele, 




Fig. 44S. — Anterior Labial or Inguinal Hernia. 



and is analogous to the serous collection sometimes found in the 
scrotum of the male. The sac is thin walled, quite translucent, 
and affords a distinct sense of fluctuation. The swelling grad- 
ually increases in size and may become so large that it is uncom- 
fortable in sitting or walking, and may prove an obstacle to the 
sexual relation. Hydrocele is readily distinguished from solid 
tumors by its translucency and distinct fluctuation ; from hernia 
by its being more continuously distended, except in the few 



GENITAL TUMORS. 



625 



cases in which the canal of Xuck remains patulous, the more dis- 
tinct sense of fluctuation, its translucency, a less amount of pain 
or discomfort, the absence of any swelling over the line of the 
inguinal canal, and the failure of the protrusion to increase during 
coughing or straining. 

Treatment. — The contents can be readily removed by punc- 
ture, but recollect rapidly. Obliterative inflammation may be 




Fig. 449. — Posterior Labial Hernia. 



engendered after the removal of the fluid by the injection of 
some irritating agent, and pressing it about to bring it in contact 
with the entire cavity of the sac, but care must be exercised to 
prevent it being forced through an open canal into the peritoneal 
cavity. A safer and more satisfactory procedure will be to miake 
a free opening into the sac and pack it Avith iodoform gauze. 

561. Erectile or vascular tumors are rare in the labium, but 
when they occur, present characteristics similar to those in other 

40 



626 



GYNECOLOGY. 



portions of the body. Vascular growths about the urethra are 
much more frequent. Pozzi indicates that the hymen is not a 
simple isolated structure surrounding the vulva, but comprises, 
first, the masculine frsnum vestibuli; second, the ring inclosing 
the urinary meatus; and, third, the hymen. The structure is 
the undeveloped matrix tissue of the corpus spongiosum in the 
male, and has not become erectile. These considerations, he 
asserts, throw light upon the origin of some of the vascular 

growths of the urethra and 
meatus. The retention of 
the erectile tissue in the 
female, which is normal in 
the male, results, through 
efforts at micturition, in the 
formation and extrusion of 
a polypus, known as a ^ire- 
thral caruncle. 

562. A urethral caruncle 
appears as a bright red, 
fragile looking projection 
from the urethral orifice. 
It is largely composed of 
dilated capillaries with a 
small amount of connective 
tissue, and is covered with 
pavement epithelium. In 
a recent study of some mi- 
croscopic sections of these 
growths I discovered the 
presence of glandular struc- 
ture quite well m.arked. The 
gro\\i;h is amply supplied 
with nerves, which are more 
or less exposed. The struc- 
ture of the growth accounts 
for its vascularity and great 
sensitiveness. (Fig. 450.) 
Etiology. — The growths 
may occur at any age. They are frequently seen in young 
children, are more frequently found in middle life, and have been 
seen in women as late as the seventy-fifth year. They occur with 
about equal frequency in the married and unmarried. 

Symptoms. — The growth usually projects from the urethral 
orifice and is generally situated upon the posterior wall. Sepa- 
rating widely, the vulva causes the tumor to be pushed forward 
and rendered more prominent. Its sensitiveness varies with 




i 



Fig. 450. — Urethral Caruncle. 



GENITAL TUMORS. 



627 



different individuals. In some it produces no marked symptoms, 
while others complain of continuous burning, a sensation of full- 
ness in the urethra, and marked pain during and for several 
minutes following urination. Occasionally the distress is so 
marked that the act of micturition is prevented and the employ- 
ment of a catheter is rendered necessary. Its extreme sen- 
sitiveness frequently causes it to be a barrier to the sexual re- 
lation, hence it is one of the causes of dyspareunia. 

Diagnosis. — The tumor 
is readily recognized by its 
bright red appearance, its ex- 
treme sensitiveness, and its 
fragility. A varicose condi- 
tion of the urethral vessels 
may occur, but this is char- 
acterized by bluish projec- 
tions from the urethral ori- ^ r.^^^ 
fice, which are plainly recog- f/f^BUL^^ I 
nized as distended veins, 
somewhat resembling hemor- 
rhoids about the anus. A 
prolapse of the urethra may 
exist, but this condition 
forms a rounded projection 
which partly or completely 
encircles the urethral orifice. 
(Fig. 451.) 

Treatment. — The only 
treatment that affords any 
hope of success is excision. 
This may be done under co- 
cain anesthesia, the mass 
picked up and cut off at its 
base with scissors, and bleed- 
ing arrested by coaptating 
the surfaces Avith a suture. 
It is much more satisfactorily 
accomplished, however, 

under general anesthesia, as the patient is then quiet and the 
manipulation can be more deliberate. The excision of the mass 
with scissors and the application of the thermocautery to the 
base are very efficient. In the employment of the thermocautery 
a wooden rod the size of a catheter should be previously intro- 
duced to preserve the urethra from destruction. Especial care 
must be exercised to control the hemorrhage, as I have seen 
frightful bleeding occur from such an operation. 




Fig. 451. — Prolapsus Urethras. 



628 



GYNECOLOGY. 



563. Varicose Veins. — Varicose veins of the vulva are not in- 
frequent during gestation. (Fig. 452.) Holden reports a case 
in which the labia majora were the size of a fetal head. The pa- 
tient died of phlebitis. The tumor presents a bluish color on 
the surface of the integument, violet on the mucous surface, and 
gives rise to a sensation of weight in walking or when the patient 
is in the upright position. The rupture of such a tumor may 
cause serious or even fatal hemorrhage. The patient should be 
cautioned to wear her clothing loose, having no constriction about 
the waist, and the varicose parts should be supported. The most 
effective treatment is the excision of the principal veins. 




Fig. 452. — Varicose Veins of the Vulva. — {Dr. W . Krusen.) 



564. Edema. — Anasarca is frequently accompanied by ex- 
tensive swelling of the labia. The cause is readily recognized by 
the associated condition. When edema exists without general 
dropsy, it is indicative of some obstruction to the circulation in 
the pelvis. Edema confined to one labium is generally the result 
of injury or inflammation. A hard, dense exudation in one la- 
bium will usually be found to be due to a hard chancre, situated 
upon the same side at the margin of the vagina. 

565. Elephantiasis. — Elephantiasis consists in chronic inflam- 
mation of the lymphatics, with dilatation of their canals. It is 
very rare in our climate, but is more likely to exist in hot climates. 
The cause of the condition is unknown. The affection consists 



GENITAL TUMORS. 629 

of more or less considerable hypertrophy of the entire vulva, 
sometimes localized in certain regions, as, for example, in the 
clitoris. The large hypertrophied labia form voluminous masses, 
which may exceed the dimensions of an adult head. (Fig. 453.) 

Three forms ate described: first, the entire derma is hypertro- 
phied, with A^ast dilatation of the lymph-spaces; second, the 
engorgement of the lymph in the capillaries and large trunks; 
third, the lymphatic ganglia become the seat of fibrous altera- 
tion. 

Symptoms. — The enlargement is frequently so great that 
walking and urination are interfered with. Friction of the sur- 
face leads to ulceration, which is slow to heal. The thickened 
tissues invade the vulva and the perineal and anal regions, and 
form enormous tumors. When the surface of the skin is smooth, 
it is called glabrous; when roughened, with warty projections, 
verrucous; and papillomatous when the papillas are much 
hypertrophied. 

Diagnosis is easy. The hypertrophy and swelling of lupus 
are always accompanied by ulceration. The papillomatous veg- 
etations are situated directly on the skin. In fibromata and 
myxomata which become pedunculated the tumors are isolated 
and circumscribed, while elephantiasis is diffuse. The cause of 
the condition is unknown, although it has been attributed to 
syphilis. It is due to an acute lymphangitis, with intense fever. 
The only effectual treatment is ablation and the suturing of the 
surface in order to secure union bv first intention. 



VULVA. 

566. Tumors of the vulva are comparatively rare and com- 
prise cystic and solid, benign and malignant, growths. 

567. Serous cysts would naturally be expected to occur in a 
region so well provided with glands as is the vulva. Retention 
cysts of the gland of Bartholin belong to this class. (See Section 

394-) 

568. Sebaceous cysts rarely attain to any size. They are 
found upon the labia majora, the labia minora, in the sulcus, 
between them, about the clitoris, over the mons veneris, and 
sometimes upon the edge of the hymen. 

569. Blood cysts are occasionally found. These may origi- 
nate in a preexisting hematoma, through a hollow, round liga- 
ment (Koppe), in the sac of an old hernia, in the site of a throm- 
bus, or from dilatation of lymph-vessels. 

Cysts are also found in the hymen — Doderlein says, from 
fusion of adjoining surfaces; in the urethra, either from ob- 
literation of Skene's glandules or the dilatation of a terminal 
and unobliterated vestige of Gartner's duct. 



630 GYNECOLOGY. 

Hematoma of the vulva and vagina has been described. 
(Section 534.) 

Abscess. — (Section 391.) 

570. Neuroma of the vulva is a rare condition. Painful 
nodules are occasionally recognized, and their presence oc- 
casions vaginismus. 

Treatment would be to excise the painful spots. 

571. Simple Vegetations. — Vegetations appear upon the vulva 
in the form of papillomata or condylomata, occasionally having 
the appearance of a cauliflower. They may be situated at 
the edge of the vulva in isolated projections, or may cover, by 
a voluminous growth, the whole surface of the external genitalia. 
The mass may extend backward around the anus, and may 
attain the size of a fetal head. The growth presents a pale 
red color, often a deep wine tint, and is situated upon the vulva, 
perineum, and margin of the anus, sometimes extending for- 
ward over the mons veneris and over the inner surface of the 
thighs. (Fig. 453.) A profuse leukorrheal discharge is gener- 
ally present, which is retained by these vegetations, and causes 
an extremely disagreeable and fetid odor. The decomposing 
discharges irritate the surface, which becomes greatly inflamed 
during w^alking and exercise. They are generally considered an 
indication of venereal infection, and are produced by either gonor- 
rheal or syphilitic virus. Transmission of the disease has been 
observed by contact. The presence of vegetations, however, 
is not always an indication of specific infection, as these growths 
arise in pregnant women from a simple leukorrhea. The sur- 
faces upon which they are implanted may become thickened 
by inflammation, undergo ulceration, and be covered by a glairy, 
fetid mucus which increases the resemblance to malignant 
disease. A vertical microscopic section of a growth, however, 
will reveal its true character. In the vegetations are dilated, tree- 
like capillaries embedded in connective tissue, and covered with 
several layers of epithelium, thus presenting a marked con- 
trast to the nests or tubular masses of epithelium embedded 
in connective-tissue stroma, which indicate the presence of 
epithelioma. 

Treatment. — Keep the parts thoroughly clean, irrigate with 
bichlorid solution (i : 2000), and dust the surface with equal 
parts of alum and sugar or paint it with carbolic acid and after- 
ward wash with alcohol. When the vegetations are very ex- 
tensive, the most effective method of treatment is to place the 
patient under an anesthetic and with scissors cut away the vegeta- 
tions, cauterize the base with nitric or chromic acid, or, still 
better, with the thermocautery, and subsequently keep the parts 
clean and dusted with a drying powder. The pain following the 



GENITAL TUMORS. 



631 



application of the thermocautery will be greatly lessened by 
painting the burned surface with carbolic acid. The convales- 
cence will be rapid. The existence of pregnancy need be no 




Fig. 453. — Vulvar Vegetations. 



barrier to the method of treatment indicated, as the danger to 
the patient from sepsis following delivery is much greater than 
any which could result from the removal of the growths. 



632 



GYNECOLOGY. 



General anesthesia can be avoided by saturating the parts 
with a ten per cent, solution of cocain. Removal of the growths 
by the curet has been advised, but the scissors affords a cleaner 




Fig. 454. — Elephantiasis of the Vulva. 



and more effective instrument. Excision produces less irritation 
of the subjacent skin. The hemorrhage may be controlled by 
the application of a strong solution of persulphate of iron, but 



GENITAL TUMORS. 



633 



the thermocautery will prove more satisfactory. The burn- 
ing of the latter can be lessened by the application of a com- 
press wet with a 5 per cent, solution of carbolic acid. The ap- 
plication of a 10 to 40 per cent, solution of formaldehyd two 
or three times will cause the vegetations to slough, but this 
is a painful application. 

572. Fibroma and myxoma are tumors which are found in 
the large labia, though they may also develop in the nymphag 
or in the perineum. They are benign tumors of slow gro\\i:h, 
though they occasionally attain to large size. The former be- 
come pedunculated. The tumor may be enucleated or the 
pedicle may be cut without danger of hemorrhage. Figure 
455 shows a fibroid tumor that occurred in the. practice of Dr. 
S. E. Cox, of Nashville, to whom I 

am indebted for the illustration. 

573. Lipoma. — A lipoma is a 
fatty tumor of the labium which 
may resemble elephantiasis. 
Through the kindness of Dr. E. 
L. Reed, of Atlantic City, I was 
permitted to see a lipoma the size 
of an orange on the vulva of a 
woman who consulted him from 
the fear that it was a hernia. Lipo- 
mata are usually small, but Stiegel 
removed one that weighed ten 
pounds. 

574. An enchondroma is an ex- 
ceedingly rare cartilaginous tumor 
which affects the clitoris. It may 
become as large as the fist and 
present calcified portions. Bartho- 
lin reports a Venice courtesan who wounded her paramour with 
her ossified clitoris. 

575. Malignant Disease of the Vulva. — Alalignant disease 
occurs in the vulva in the form of epithelioma, sarcoma, and 
rarely as adenocarcinoma. Primary cancer of the vulva is 
rare. Epithelioma is the most frequent form and. begins in the 
large labium or in the cleft between it and the lesser labium, 
less frequently in the clitoris or the meatus. The disease origin- 
ates from the squamous epithelium and usually appears first as 
small warty nodules covered with thick layers of epithelium. 
Sometimes it follows irritation about the base of a preexisting 
papilloma or wart. It is frequently preceded by psoriasis. The 
epithelium covering the nodules undergoes degenerative changes 
and causes a discharge of thin watery fluid mixed with blood. 




Fig. 455. — Fibroid of Labium. 



634 



GYNECOLOGY. 



Groups of the embryonic cells fracture the limiting membrane 
and penetrate deeper tissues, supplanting the normal tissue and 
forming the characteristic epitheHal pearls. Sometimes the 
cells will be found in the act of penetrating the walls of the 
blood-vessels, thus expediting the propagation of the disease. 
As the infiltration advances, superficial ulcerations occur, which 
gradually become deeper and involve the neighboring structures. 
(Fig. 456.) The inguinal glands are first sympathetically in- 




Fig. 456. — Cancer of the Vulva. 



volved and later become infiltrated with the malignant cells. 
The disease occurs upon one side and then spreads to the oppo- 
site, possibly by inoculation through apposition. Adenocarci- 
noma results when the disease begins in the glands of Bartholin. 

Sarcoma occurs in the simple form as the melanosarcoma. 

Symptoms. — -The patient suffers from* intense pruritus, in 
scratching for which the nodules, previously unnoticed, are 
discovered. These become excoriated and cause a bloody 



GENITAL TUMORS. 



635 



discharge and an exceedingly fetid odor; not infrequent!}^ the 
nodule is a wart which has become irritated at its base and 
subsequently infiltrated. The nodules may be sessile or pedun- 
culated, and subsequently coalesce. When the disease occurs 
about the urethra, the orifice may become contracted, and 
the canal may appear as a hard, indurated cylinder. The 
ulceration presents excavated borders, with the adjacent skin 
infiltrated and hard, and the pubic hair may fall out. In the 



r 




0/ 




1- 



Fig. 457. — Appearance of the Vulva after an Operation for Cancer of the Vulva. 



later stages the skin and tissues for some distance around the 
vulva become indurated and hard, and the glands of the groin 
are infected. With the extensive inflammation, the discharge, 
loss of blood, loss of rest, and the mental anxiety produce emacia- 
tion, and death follows from marasmus, sepsis, or metastatic 
development. The latent period is a long one, the disease 
remaining for some length of time with but slight circumjacent 
or more extensive involvement. Death occurs in the second 
or third year. 



636 GYNECOLOGY. 

Diagnosis. — The history of continued genital psoriasis; in- 
tense pruritus, with small nodules ; arrangement of the epithelial 
layer, which shows a tendency to break down; the irregular ul- 
ceration, with infiltrated base and margins ; and, later, glandular 
involvement, are sufficient to indicate the character. Papillary 
vegetations extend over a considerable surface, are comparatively 
free from induration, and in no sense resemble cancer. A pol- 
ypus or caruncle of the urethra has a base free from induration. 
Chancre is an indurated sore without disposition to spread, and 
is associated with glandular involvement, and later with the 
syphilitic eruption. Chancroid is a superficial ulceration without 
induration. The contiguous surfaces readily become inoculated. 
The lymphatic glands promptly go on to suppuration and to 
the formation of buboes. In lupus the ulceration is serpiginous, 
with a tendency to cicatrization in the tissues first affected, 
and glandular involvement is rare. 

The prognosis of malignant disease of the vulva is bad. 
The cases usually come under observation after extensive 
involvement, generally after the lymphatic system has become 
invaded by the malignant process. Operative treatment delays 
the progress of the disease and renders the patient more com- 
fortable. 

Treatment. — The only hope for the patient consists in total 
removal of the disease. Some prefer the thermocautery or 
galvanocautery to the knife, as affording less danger from 
secondary inoculation. The scissors or the knife, however, 
are preferable, as by their use we shorten the convalescence 
and leave the structures less distorted. Care must be exercised, 
when possible, not to injure the meatus. In peri-urethral cancer, 
however, the sound should be introduced into the bladder, 
which will aid in the dissection, and the neoplasm, if neces- 
sary, should be followed to the neck of the bladder. In one 
case I removed the urethra up to the neck of the bladder without 
the patient suft'ering from incontinence. The incision should ex- 
tend well around the disease, as far as possible within the bounds 
of healthy tissues. Bleeding vessels, rather frequent in this 
region, are secured with clamp forceps, and ligated if neces- 
sary with catgut ligature, or the sutures closing the wound 
are so introduced as to constrict the bleeding vessels. Care 
must be exercised that the bleeding vessel does not retract and 
continue to bleed. The retraction thus of branches of the 
internal pudic caused hemorrhage which followed the pelvic 
muscles backward, broke through and formed a large hematoma 
upon the posterior surface of the sacrum, in one of my early 
operations for this condition. In such a case, if the vessel can 
not otherwise be secured, it will be better to tie the internal 



GENITAL TUMORS. 637 

pudic over the external surface of the spine of the ischmm. 
Fig. 456 illustrates the case of a woman who underwent opera- 
tion in which both labia and clitoris were removed, and the 
tissue subsequently united, as seen in Fig. 457. Any inguinal 
glands involved should be extirpated, as well as the principal 
chain of lymphatic vessels leading to them. The circumjacent 
fat and cellular tissue should also be removed. When the disease 
has progressed too far to render radical operation successful, 
the putrid discharge may be temporarily controlled by the use 
of the curet and cautery. When the disease is too far advanced 
for this, the surfaces may be kept sprinkled with iodoform and 
pure charcoal, and dressed with gauze. The surface can be dusted 
with the following powder: 

B . Salicylic acid, gr. iv 

Boric acid, .^ j 

Iodoform, ^ij 

Ext. eucalyptus, q. s. 

Kraske advises in extensive disease that the parts be thor- 
oughly cureted, the lacerated parts cleansed, and the surface cov- 
ered with flaps of healthy skin, as this procedure renders the 
course of the disease slower and the symptoms less painful. 



VAGINA. 

Tumors originating in the structure of the vagina are infre- 
quent. 

576. Cysts of the vagina are very rare, and are generally 
formed in the remains of congenital structures. (Fig. 458.) 
They are found as isolated tumors in the mucous and submucous 
membrane, in the former usually directly beneath the squamous 
epithelium. Rarely more than two or three occur in any indi- 
vidual case; Schroder, however, removed six from one patient. 
They are more frequently found upon the anterior wall, and 
are exceedingly rare upon the posterior. They vary in size 
from that of a pea to a hen's egg. The contents of these cysts 
are serous, more or less viscid or gummy, and are sometimes 
found mixed with blood. The epithelial lining of the sac may be 
either cylindric or laminated. The epithelium of some is ciliated 
(Abel). The origin of these growths is exceedingly diflicult to 
determine. They have been attributed to the remains of 
Mliller's, Wolff's, and Gartner's ducts, to vaginal glands, or, 
according to Klebs, to dilated lymphatics. Neugebauer attri- 
butes most of them to remains of Gartner's canal. Hematoma 
of the vagina may serve as the origin for a cyst. Glands of the 
urethra may form retention cysts, and, as they develop, may 
project into the vagina. 



638 



GYNECOLOGY. 



The symptoms will depend upon the size of the cysts. Or- 
dinarily, they produce no inconvenience nor discomfort. Re- 
cently a patient underwent examination for some pelvic dis- 
order, when a cyst the size of a walnut was found upon the 
posterior wall. 

Diagnosis. — The condition may sometimes be mistaken for 
cystocele or urethrocele. The use of the catheter during the 
examination will demonstrate the thickness of the septum 

and the presence and size 
of the cyst. In the upper 
part of the vagina cysts are 
confounded with small tu- 
mors in Douglas' culdesac, 
such as prolapsed ovaries, 
a noncystic inflammatory 
condition of the tubes, and 
other inflammatory collec- 
tions. A second vagina, 
which is closed and filled 
with retained secretion, may 
simulate a cyst. 

Treatment. — Only the 
large cysts require any 
treatment. The cyst may 
be opened and the sac 
cauterized most effectually 
with the actual cautery; 
or it may be packed with 
iodoform gauze, which af- 
fords drainage and sets up 
sufficient inflammation to 
obliterate it; or the entire 
sac may be enucleated. 

577. Fibroid Tumors and 
Polypi. — Fibroid tumors 
originating in the vagina 
are very rare. They de- 
velop in the submucous or 
deeper layers of the mucosa and push into the vagina. As 
they increase in size they become polypoid, and hang by a 
pedicle. The structure is similar to that of uterine fibroids, 
and the gro^vth is slow. The most common situation is the 
superior portion of the anterior wall. They are often adherent 
to the urethra, and distend the vulva. They are usually small, 
although they have been reported as weighing two and one- 
half pounds. Bandier and Gremlier report one weighing ten 




Fig. 45 8. — Cysts of the Vagina. 



GENITAL TUMORS. 



639 



pounds. I am indebted to Dr. John C. DaCosta for the illustra- 
tion (Fig. 459) of a specimen which he removed from the vagina. 
As these growths increase in size, they become softened and 
ulcerate. They are much more likely to develop during the 
period of sexual ' activity, although Tratz reported one in a 
child of fifteen months which attained the size of a man's fist, 
and Martin one f of an inch long in a child two days old. 

Symptoms. — The symptoms of the growth are largely de- 
pendent upon its size. If small, the tumor may remain unrecog- 
nized. Larger growths cause 
dysuria and retention of 
urine. They project from 
the vulva, and the traction 
produces bleeding, ulcera- 
tion, and erosion. 

Diagnosis. — The growths 
are readily determined by 
their situation, slow growth, 
and mechanical disturbance. 
The softening, ulceration, and 
hemorrhage may sometimes 
lead to a diagnosis of malig- 
nant disease. 

Treatment. — The treat- 
ment consists in the removal 
of the growth by enucleation 
in sessile tumors, and by sec- 
tion of the pedicle in polypus. 
Hemorrhage is controlled by 
ligature or suture. 

578. Papillomata. — Papil- 
lary or warty growths are 
found in the vagina, gener- 
ally in association with simi- 
lar growths about the vulva. 
Generally they appear as 

small isolated projections over the walls, but occasionally the 
entire vagina will be filled. 

579. Malignant Neoplasms. — In the vagina malignant growths 
of primary origin are very rare. They most frequently extend 
from the uterus, rectum, vulva, urethra, or bladder, in one of 
three forms: first, papillary; second, infiltrated or nodular, both 
of which are included histologically under epithelioma; third, 
sarcoma, either diffuse or circumscribed. They most frequently 
occur in the papillary form, although we may have carcinomatous 




Fig. 459. — Myoma of the Anterior Vag- 
inal Wall. — (^Dr. John C. DaCosta.) 



640 



GYNECOLOGY. 



infiltration, either circumscribed, forming a broad-based excres- 
cence, or a substitution of scirrhous for the normal tissue. 

Etiology. — Malignant disease is most frequent during middle 
age, and is rare in youth, although I have seen one case of cancer 
of the vagina in a woman twenty years of age. Hegar once saw 
it in a woman in whom it was attributed to the irritation pro- 
duced by a pessary. Epithelioma of the papillary form usually 
affects the posterior wall, as a broad-based excrescence which 

rapidly invades the 
culdesac and ex- 
tends downward to- 
w^ard the vulva. 
Epithelioma of the 
nodular or infil- 
trated form appears 
as nodules which 
become confluent, 
sometimes localized 
about the wall of 
the urethra. The 
ulceration advances 
rapidly, and may 
burrow into neigh- 
boring organs, pro- 
ducing rectovaginal 
or vesicovaginal fist- 
ula. The disease ex- 
tends by the lymph- 
atics to the pelvic 
cellular tissue ; when 
it is situated in the 
anterior wall, the 
lymphatic glands of 
the groin are also in- 
volved. 

Symptoms. — Va- 
ginal epithelioma 
very early causes 
hemorrhage, which will be aggravated by locomotion, coition, 
and the various procedures in examination. There is a profuse 
purulent discharge which is exceedingly offensive ; pain is not so 
marked as in disease of the uterus, unless in the later stages. The 
principal symptoms are the mechanical obstruction to coition 
and to delivery from stenosis, and the watery, bloody, and offen- 
sive purulent discharge. In a case recently under observation 
the disease had involved the anterior wall of the vagina, having 




Fig. 460. — Primary Cancer of the Vagina. 



GENITAL TUMORS. 641 

apparently originated in the urethra, and formed a large scirrhus- 
like mass extending upward over one-half the anterior vaginal 
wall. The patient suffered from great inconvenience in urina- 
tion, having frequent attacks of retention and severe pain. 

Sarcoma. — Salrcoma occurs in two varieties: first, the dif- 
fuse sarcoma of the mucous membrane, often seen in young 
children; second, fibrosarcomatous growths, or melanotic sar- 
coma. Epithelioma, or cancer, may be distinguished from sar- 
coma by the use of the microscope. In the former we note the 
characteristic assemblage of the epithelial cells, forming the 
pearly bodies, and preservation of the walls of the blood-vessels; 
while in the latter, the cells are more or less unconfined by 
connective -tissue stroma and the blood-vessels appear as mere 
sluiceways or blood-channels. 

Treatment. — The thin wall of the vagina is very slightly 
resistant to the progress of malignant disorder, and the dis- 
ease is rapidly transmitted by the lymphatic vessels to the deeper 
cellular tissue of the pelvis, so that by the time the patient 
affected with cancer or sarcoma comes under observation, very 
little can be done in the way of treatment beyond relieving her 
from the discomfort produced by the accompanying symptoms. 
Complete recovery is rare. Eiselsberg, in a case of cancer which 
involved the whole of the rectovaginal septum, resected the 
coccyx and established an artificial anus in the sacral region 
after extirpating the whole of the diseased part. The patient 
rapidly recovered and had control of her stools. In a patient 
of mine, when the disease had proceeded from the rectum, 
involved the posterior wall of the vagina and the perineum, 
and extended close to the cervix, I removed the coccyx, re- 
sected the sacrum, excised six inches of the rectum, removed 
the ovaries, tubes, entire posterior wall of the vagina, and 
the posterior commissure of the perineum. The rectum was 
stitched to the sacrum posteriorly, and to the anterior wall 
of the vagina anteriorly, the peritoneum having been pre- 
viously closed. (See Fig. 530.) A colostomy had been per- 
formed upon the patient before she came under my obser- 
vation. After the patient had recovered from the pelvic opera- 
tion the opening in the intestine was dissected, out and the 
two ends of the bowel were reunited. The patient was under 
observation for nearly thirteen months. The contraction of 
the intestine at the site of the former colostomy was sufficient 
to give the patient warning of the passage over it of feces, so 
that she could prepare herself for the evacuation of her bowels 
and avoid soiling her clothing. 



41 



642 GYNECOLOGY. 



BLADDER. 

580. Tumors of the Bladder. — Benign new-growths of the 
bladder are claimed to be very rare in the female; the most 
frequent are the villous polypi, called by Rokitansky villous 
cancer. Albarran declared that every tumor of the bladder 
was malignant. The frequent -deaths from uncontrollable hemor- 
rhage and relapse would seem to justify such a diagnosis, but 
after careful microscopic investigation of the anatomic structure 
of the tumor by Virchow, he asserted that it was not correct, 
and called the tumor fibropapilloma or villous polypus. The 
growth is most frequently situated on the lower surface or over 
the trigonum, though occasionally found upon the fundus 
and in vesical diverticula. It is sometimes completely pedun- 
culated, so that several berry-like masses are situated upon 
a single stem, which is easily torn. In women these tumors 
are more frequently pedunculated, while in men they have 
a broad base or present as multiple tumors. With water in 
the bladder they float about like a water-plant. Sometimes 
there are several masses of various dimensions, like grapes 
or raspberries, upon a single pedicle. The tumors grow very 
slowly. These growths absorb water, and consequently be- 
come very much shriveled when kept in alcohol. Microscopic- 
ally, they consist of a thick portion, which ends in villi of thin 
connective-tissue frame and many large vessels. Vessels are 
often so well developed that they completely supplant the 
frame. The epithelium is then situated almost completely 
upon the vessels. In other cases the connective -tissue frame 
is thicker, so that one would incline to pronounce it a fibro- 
papilloma. The under layers of the epithelium are cylindric 
in form, while the superficial are polygonal and the epithelium 
sends in no processes. We do not find nests or alveoli in the 
connective tissue, so the characteristic structure of cancer 
is wanting. The base of the bladder-wall is thickened and 
infiltrated, a centimeter in thickness, which forms a crust dis- 
tinctly recognizable during operation. The tumor itself is firm 
or soft, according to the thickness of its stroma. The pedicle is fre- 
quently so soft that, in an operation, an attempt to tie it results in 
the thread cutting through or tearing it off. The large blood- 
vessels contained in the connective-tissue frame lead to engorge- 
ment, and not infrequently to strong venous hemorrhage. This 
is the principal symptom of the villous polypi. These polypoid 
multiple tumors may fill the entire bladder. They may even 
pass through the urethra to the external orifice. 

581. Mucous Polypi. — In cystitis not only enlarged papillae, 
but also mucous polypi, are observed. These growths have 



GENITAL TUMORS. 643 

a smooth surface without papillomatous arrangement, and 
are poorly supplied with blood-vessels. Occasionally, they 
attain considerable size — from five to seven centimeters in 
diameter. 

582. Myoma.-^A myomatous tumor of the female bladder 
is much more rare than in man. The tumors are hard, whitish 
upon the cut surface, arise from the vesical muscular struc- 
ture, and grow into the wall or become pedunculated. With 
the gradual thinning of the pedicle the tumor loses vitality 
and becomes partly destroyed. 

Cystic or softened myomata are also recognized. 

Dermoid of the bladder has been observed (Thompson). 

Symptoms. — The most characteristic symptom is hemor- 
rhage. The bleeding is very likely to occur in the night, per- 
haps owing to congestion from being warmly covered in bed. 
Bleeding takes place without any other symptom, and must 
be carefully investigated, as the patient will frequently assert 
that it comes from the vagina. The hemorrhage may sud- 
denly cease, and the urine the following day be perfectly clear, 
to continue so for a number of weeks, when bleeding again 
recurs. After the tumor exists for some time, bleeding will 
become continuous. 

Pain may be absent for years. 

Cystitis does not necessarily exist. Indeed, small tumors 
may have no influence upon the mucous membrane; floating 
in the urine, they do not injure its epithelial surface. In spite 
of long-existing growths, we will find the bladder surface pale 
from the general anemia. 

When hemorrhage ^ leads to the suspicion of the existence 
of vesical tumors, the use of the catheter must be practised 
with care. The touch of the instrument causes injury; por- 
tions of villous growths float into the eye of the catheter and 
are torn off. Such masses should be carefully examined. 
Tumors of the trigonum float into the internal urethral orifice 
and obstruct the flow of urine. In long-existing tumors the 
urine becomes progressively bloody, coffee-like, or brownish. 
The surface of the tumor, from which the blood arises, appears 
black, red, sometimes opaque, or a bright red. The continuous 
vesical hemorrhage leads to intense anemia, although it is sur- 
prising how long the patient will endure it. Gradual emacia- 
tion, and finally cachexia, appear. The disease may extend 
over a period of many years. 

Diagnosis. — Examination is practised by palpation with 
two fingers of one hand in the vagina, while the fingers of the 
other are placed over the abdomen. The patient lies upon a 
table or hard couch. If the bladder is emptied with a catheter, 



644. GYNECOLOGY. 

one must remember its danger. The examination is made 
slowly, carefully, and systematically. Generally, the abdominal 
walls are easily depressed. When the patient is unable to 
relax them, an anesthetic should be given. By careful in- 
vestigation a tumor as small as a hazel-nut can be recognized, 
but pedunculated gro\^1:hs may easily be displaced to one side 
and elude the grasp, and leave one in doubt as to their presence. 
The ovaries are not unusually so situated that they may be 
felt, and lead to the belief that a vesical tumor is present. The 
cystoscope aids in clearing up doubt. Diagnosis should not 
be based alone upon palpation. The urine should be examined 
chemically and microscopically. Cylinder-like cells are char- 
acteristic of papilloma. The older writers placed great stress 
upon the character of the hemorrhage — whether fluid blood, 
worm-like clots from the ureters, blood only, in the first or 
last portion of urine, or pure blood followed catheterization. 
These distinctions afforded differential diagnosis between renal 
and vesical hemorrhage, but are now considered of little value 
as compared with cystoscopy. By direct investigation the 
relation of the tumor to the vesical wall is observed, and bloody 
urine can be seen flowing from the orifice of a ureter. The 
bladder can also be investigated by touch with a finger intro- 
duced through the urethra, but this should be practised with 
the greatest prudence, and, preferably, with the little finger 
only, because overdilatation may result in incontinence. 

Treatment. — The one treatment for vesical tumors is opera- 
tive. Following the diagnosis, the operative procedure should 
be employed as soon as the condition of the patient will per- 
mit. High fever, suppuration, cystitis, and marked anemia, 
are considered as contraindications. 

The removal of the growth is surprisingly easy. New loss 
of blood is endangered by ever^^ day's delay. Suppuration 
is not a contraindication. If the tumor is large, irrigation 
with the syringe does not secure disinfection, and suppuration 
ceases only after the complete removal of the mass, and thus. 
the danger of nephritis is lessened. 

The tumors may be reached through the urethra by the 
urethral speculum. The masses are seized with forceps and 
torn off, cut through by the galvanocaustic loop, cut away 
with scissors or forceps, or scraped off with a sharp curet. The 
latter instrument, however, should be used only when the 
finger can be introduced as a guide. Whatever method is em- 
ployed should be thorough. In large, broad-based, friable 
tumors much injury may be done by scraping or tearing. The 
bladder soon fills with blood, which is hard to remove and 
decomposes, and the necrotic masses often cause cystitis and 



GENITAL TUMORS. 645 

suppuration. Syringing the bladder with ice-water and as- 
tringents is painful. 

If the pain, loss of blood, and cystitis are aggravated by 
the operation, it is hard to convince the patient that anything 
has been done for her relief. In extensive involvement or growths 
with a broad base the preliminary incision of the bladder is 
more effective and satisfactory, as by it the diseased structure 
and the field of operation are exposed to view and to more 
effective manipulation. 

Vaginal Incision. — As a guide a catheter is introduced into 
the bladder, upon which a longitudinal incision is made through 
the middle line of the vagina, about five centimeters long, of 
sufficient length to permit the introduction of two fingers. 
The incision can be enlarged with scissors or with a knife above 
and below, affording considerable exposure of the bladder and 
its morbid growths. 

Bleeding vessels are secured by pressure forceps. The 
growths are then removed with forceps, scissors, knife, fingers, 
the galvanic loop, or the Paquelin cautery. In copious hemor- 
rhage syringe with either ice-water or quite hot water; cotton 
sponges wet with the latter may be pressed upon the bleeding 
surface. Sutures can not well be used, because they cut through. 
The precaution must be exercised to avoid injuring the ureters. 
Hemorrhage is very severe in these operations and greatly 
obscures the view. The fistula should be closed, a catheter 
introduced, and the vagina tamponed to compress the bladder 
and decrease the bleeding. An ice-bag should be applied over 
the lower abdomen. 

The trifling mobility of the bladder in the region of the 
trigone renders it difficult to expose a bleeding vessel through 
the vaginal incision, and the bleeding renders the field but 
little more accessible to view than through the dilated urethra, 
while through the latter the organ can be tamponed even more 
effectively than by the vaginal incision. It has been advised 
that operation for removal of tumors of the bladder should be 
preceded by double nephrotomy for the establishment of drain- 
age. Such a procedure may be of value in extensive vesical 
operations, but the discomfort of lying continuously in a pool of 
urine is so great that it should be infrequently employed. 

Abdominal Incision. — The sovereign procedure is the high 
bladder incision. A transverse incision gives more room than 
a vertical, though the two may be combined in a T-shaped 
cut. The difficulty in securing firm union and thus avoid- 
ing subsequent ventral hernia, how^ever, precludes its practice. 
The vertical incision requires strong traction to be made on 
each side. Fritsch prefers the transverse incision, claiming 



646 GYNECOLOGY. 

that recovery is excellent if the incision is not made too long — 
not over six or seven centimeters. The scar so disappears 
under the hair of the mons veneris that subsequently it is no 
more seen, even if the wound heals by secondary intention. 
It has the additional advantage that large vessels are not likely 
to be cut. He has seen a number of cases in which extensive 
hernia had formed above the symphysis, but these were cases 
in which the object of the operation had been castration, supra- 
pubic transverse section had been employed in the operation 
for castration, or cases in which the Trendelenburg posture 
had been employed for operations upon bladder fistula. In 
all these cases the scar tissue could still be seen. In twelve 
of these cases the incision had been twelve or more centimeters 
long. Such an extensive incision is unnecessary in bladder 
operations. If the incision is made shorter, the recti unite 
with a firm scar to the pubic bone. 

Fritsch describes the procedure as follows: The patient 
is placed in the Trendelenburg posture, with pelvis elevated, 
and the mons veneris and vagina are thoroughly cleansed. 
The bladder must also be thoroughly irrigated; the vagina, 
for the reason that the fingers may be required to be intro- 
duced into it, in order to penetrate the bladder from above. 
The bladder should be irrigated with several liters of boric- 
acid solution. It is better to employ a large quantity of water 
than a trifling quantity of disinfectant, solution. If the urine 
is clear or the discharge of blood quite fresh, syringing is un- 
wise, as it can easily cause a hemorrhage. An assistant places 
his hands upon the abdomen in such a way as to keep the mov- 
able skin fixed, while a transverse incision is made above the 
symphysis. The' point at which the incision is to be made 
should be fixed before the skin is put upon the stretch; other- 
wise upon drawing it up it may be found that the incision is 
too low. It should be made directly over the upper border 
of the symphysis. While one is operating in the loose fatty 
tissue behind the symphysis, an assistant pushes up the bladder 
with a thick male catheter. The projection made by the end 
of the catheter is readily seen, the tissue above it is picked 
up with a tenaculum, and the bladder-wall is cut transversely 
above the end of the catheter. As soon as the bladder is opened 
the margin on either side is seized with a pair of pressure for- 
ceps and the bladder is prudently drawn down so that the 
forceps will not tear. The catheter is removed and the incision 
extended right and left by scissors until a broad wound is made 
in the vertex of the bladder, which will permit one conve- 
niently to enter it with two fingers and inspect its inner wall. 
In this, as in all operations, it is important to proceed rapidly. 



GENITAL TUMORS. 647 

The margin of the bladder is seized by ten or twelve pressure 
forceps, which hold the bladder open automatically and make 
its cavity visible. To sew the bladder to the margin of the 
wound would take more time. If the tumors are large and 
deeply situated, they may be discovered to the right or left 
by two fingers. 'The pedicle is seized between the fingers and 
the tumor prudently drawn up. As the structure tears easily, 
the bleeding point may sink back and vanish from view^; when 
the bleeding is copious, one may be in doubt just what shall 
be done. It can be controlled promptly only through tam- 
ponade, which takes time; consequently, it is important, if 
possible, not to tear the tumor. 

Having fixed the situation of the tumor, one must make 
accessible the pedicle. This not infrequently may require 
an enlargement of the skin and bladder section. To avoid 
this, an assistant seeks to enter the vagina, and presses up- 
ward in the region of the pedicle. Hemorrhage may be con- 
trolled by a Paquelin thermocautery. The smallest points 
should be employed, in order to avoid extensive burning of 
the epithelium of the bladder. The ideal procedure is the 
employment of the galvanocautery. In small polypi and 
very small tumors the galvanocaustic loop does not act so well. 
To tie them off is, of course, difficult, as the thread easily cuts 
through. Frequently the base can not be encircled, on account 
of the proximity of the ureters. If we pass a ligature deeply 
in the firm tissue, we may injure or occlude the ureter. A 
hot iron is not effective in arresting the bleeding, and vet this 
must be controlled in order to proceed. More favorable action 
is accomplished by long and continued direct compression 
of the wound from the vagina and bladder. A strong vaginal 
tampon has a good influence. Ice-water may be used with 
advantage, and influences the closed bladder still better. In 
the open bladder the influence is not direct on the bleeding 
vessels, as the bladder muscle, like that of the uterus or the 
placental part, contracts on the bleeding surfaces. When 
the pedicle is quite visible, so that with the Paquelin one can 
touch the proper place, we should employ the scissors to cut 
the growth away. The smooth, well-marked, cut surface can 
be compressed by the finger of the assistant, in the vagina, 
with a certain advantage. It may be necessary to tamponade 
both vagina and bladder and to apply a firm abdominal bandage. 
This method is effective in controlling hemorrhage. 

The means by which hemorrhage is to be controlled must 
be rapidly determined upon, whether it be the Paquelin, the 
application of a solution of iron, syringing with ice-water, or 
surrounding with needle clamp forceps. The tampon should 



648 GYNECOLOGY. 

be prepared beforehand, and should be ready. In large, broad- 
based, villous grovvi:hs we should work with sharp curet and 
scissors. Hemorrhage is often quite considerable. If the 
tumor is situated in the trigonum, so that there is no danger 
of injury of the ureter, the base of the bladder-wall can be 
penetrated and ligated. The possible discharge of urine through 
stitch-holes is of no significance, for in Shucking's operation 
for uterine fixation it is probable that the needle has frequently 
entered the peritoneal cavity, and it is only in rare cases that 
peritonitis appears. The necessity of preventing hemorrhage 
by a tampon after the operation excludes the possibility of 
complete suturing of the wound. We can, of course, draw 
together the bladder wound somewhat, as well as diminish 
that in the skin by lateral sutures, but in the middle it must 
be kept open for the eventual renewal of the tampon. In 
such cases it should be the rule to sew the bladder to the skin 
wound, in order to make its cavity accessible and to secure 
the tissue behind the bladder from overlying urine and wound 
secretion. As the patient recovers, the bladder suture cuts 
through, the organ sinks back, and the wound opening is gradu- 
ally closed by granulations. When the opening continues too 
long, it should be narrowed by suture after artificial freshen- 
ing of the wound. A permanent catheter should be intro- 
duced, which is necessary in all bladder injuries. With an 
incision into the bladder vertex, or in bladder resection, do 
not completely close the bladder wound, but place a strip of 
iodoform gauze in the opening left in the wound. It has re- 
peatedly occurred that the patient accidentally or purposely 
has had the catheter removed, when the urine can flow from 
the wound without injury; but if the wound is entirely closed, 
the removal of the catheter would work injury to the processes 
of recovery. After the bladder tampon is removed hemor- 
rhage rarely occurs. Bloody urine disappears in from twenty- 
four to thirty-six hours after the removal of the tampon. While 
the catheter remains, the bladder should be irrigated with 
astringents or a weak solution of liquor aluminii acetici. This 
direction applies also to the external wound, and the pledget 
should be wet with the same solution. The upper wound 
has a great tendency to close. If the granulations are weak, 
as in anemic patients, they can be stimulated by dilute alcohol, 
camphor, silver salts, or tincture of iodin. The appetite, which 
is lost through an excessive flow of blood from the tumor, im- 
proves, and the patient gains rapidly in weight. The patient 
should be permitted to rise from bed as soon as the wound 
is healed. When the operation is very late in the progress 
of the disease, the wound remains unaltered, the patient does 



GENITAL TUMORS. 649 

not recover from the anemia, and does not regain her appetite. 
Whether the patient dies from loss of blood, from loss of strength, 
or from the influence of the operation, is difficult to determine. 

583. Carcinoma. — Klebs asserted that cancer of the bladder 
always began in tjie prostate. Had this assertion been correct, 
woman should be exempt from the disease. Primary cancer 
of the bladder has been described by a number of investigators. 
Bode alone has seen fourteen cases. Cancer appears as a harden- 
ing and thickening of the bladder- wall, which is covered with 
several layers of epithelium. Small tumors form in the per- 
iphery, sometimes as isolated masses, while complete infiltra- 
tion of the entire bladder is very rare. Following the destruc- 
tion of the epithelium, destructive ulceration of the cancer 
occurs. This takes on a malignant character if putrid germs 
appear in the bladder. 

Symptoms. — The urine smells like carrion; there is pain 
and vesical tenesmus. By rapid increase the carcinoma breaks 
through externally. High fever appears. The bladder with 
rapid gro\\1:h of carcinoma is fixed in contraction in the para- 
vesical tissue. With the peritonitic irritation there is increased 
sensibility. The disease extends up to the ureters, and develops 
pyelitis on both sides, interstitial abscesses, or nephritis. If 
death has not already taken place, it occurs from high fever 
and profound cachexia. It is found that the ureters become 
dilated as a result of the pressure upon those portions situated 
within the bladder-wall. 

Uterine cancer presents symptoms similar to those induced 
by villous tumors. If infiltration of the bladder-wall takes 
place, symptoms of cystitis appear. It is sometimes asserted 
that after extirpation of villous tumors carcinoma occurs in their 
place, but pathology does not seem to sustain this assertion. 
The existence of malignant disease does not contraindicate opera- 
tion, though it is necessary, in order to remove the matrix of the 
tumor, that a portion of the bladder-wall should be removed in 
order to operate in healthy tissue. In the adoption of this prin- 
ciple a portion of the bladder-wall, the trigonum, must be 
omitted. To remove it, we must remove the ureters, or at 
least the place at which they enter the bladder. Bardenheuer, 
in a case of extensive disease of the bladder, through an abdom- 
inal incision upon it, shoved back the peritoneum, loosened 
the bladder as far as possible from the perivascular tissue, 
raised it up, incised it longitudinally, secured.it with sutures, 
and drew it into the abdominal wound. The now exactly 
determined tumor is, with an elliptic piece of the bladder-wall, 
excised, and the wound margiQs are united by continuous 
suture, sparing the mucous membrane. Finally, the belly wall 



650 GYNECOLOGY. 

is sutured and a continuous catheter introduced. Wassiljew 
reports a case of total extirpation of the bladder for malignant 
tumor. The ureters were secured outside the bladder and 
sutured in the belly wall. The patient recovered, although 
both ureters became necrotic in two centimeters of their course ; 
but the pyelonephritis improved, as well as the general con- 
dition. Bensa describes a case in which a greater portion 
of the bladder was extirpated on account of an infiltrated car- 
cinoma of the right bladder-wall in a woman fifty-one years 
old. The operation was accomplished by a median incision 
in the mons veneris; the symphysis pubis was separated and 
the bladder opened and loosened subperitoneally, except on 
the right side, where the peritoneum tore, but was immediately 
sutured again, then loosened on the left side; the left ureter 
was resected, and the under part of the right ureter, because 
it had been invaded by carcinoma. The ureters were replaced 
in the small remains of the bladder, which was closed by sutures. 
The symphysis was .then closed with silver wire sutures and 
the wound tamponed above and below the symphysis. The 
patient died the day after the operation. Bensa holds total 
bladder extirpation as indicated, first, in benign tumors if 
they are multiple and produce sufficient disturbance of the 
bladder function; second, in infiltrated malignant tumors if 
they occupy the greater part of the bladder-wall, third, in 
large, broad-based tumors of the base of the bladder. The 
entire bladder has also been resected for tuberculosis. How 
much advantage is to be obtained from these procedures is 
a question. Narrowing of the ureters in the artificial bladder 
and small abscesses from implantation and sutures cause dis- 
turbance for months, even though the case has been quoted 
in literature as a successful result. After extirpation of the 
bladder the ureters have been implanted in the vagina. While 
the vagina is normally aseptic, it is questionable how long 
it will so remain with this additional abnormal function. 



UTERUS. 

584. Fibromyomatous Tumors. — Myofibromata are benign 
growths of the connective-tissue order which occur in the cer\dx 
as well as in the body of the uterus. Their structure consists of 
connective tissue or of muscular combined with connective 
tissue. Where the connective tissue predominates, they are 
designated by the term fibromata, and where the muscular tissue, 
as myomata or fibromyomata. The pure myomata consist only 
of muscular structure and exist only in the early stages. They 
usually appear singly and may attain rather a large size. 



GENITAL TUMORS. 651 

The myomata are the most frequent form of uterine growths. 
Careful examination will disclose such a growth in 20 per cent, 
of all the women who have reached the age of thirty-five years 
(Bayle), in 40 per cent, of women of fifty years (Klob), but 
in the great maj6rit3^ "^^^ tumors are small. The gro\Ai:h of a 
tumor is very slow; when rapid increase in volume is observed, it 
arises, not from an increase of tumor elements, but from a dis- 
turbed condition of tissue fluid, which will be considered later. 
The most favorable condition for rapid gro^^^h is an intimate 
vessel union with the uterus. 

It is the generally accepted view that fibroid growths in- 
crease in size only during the period of sexual activity, and 
remain stationary or undergo atrophy after the climacteric. 
It is quite probable that no myoma ever originates in the uterus 
prior to puberty or subsequent to the menopause. A tumor 
has been reported as having been found in the uterus of a girl 
aged ten years, but no opportunity was afforded to demon- 
strate the correctness of the diagnosis by microscopic inves- 
tigation. 

Sutton has reported a childless widow, who had never men- 
struated, as having carried such a tumor for ten years. Peter 
Muller and Joseph Taber Johnson both assert that the growth 
sometimes continues to increase after the cessation of men- 
struation. Hofmeier says that such increase occurs in those 
myomata which stand in nutritive union with the peritoneum 
through organized bands of adhesion. The truth of this is 
especially indicated in omental adhesions, which greatly in- 
fluence the progress of the growth. He cites a woman in whom 
a thirty-flve pound myoma, w^ith numerous interstitial and 
omental adhesions, had continued to grow for a year after the 
menopause. 

A myoma is rarely found alone in the uterus. The dis- 
ease generally exists as a multiple tumor formation. Over 
fifty growths have been found in one uterus. J. Bland Sutton 
recently removed a uterus which contained one hundred and 
twenty myomatous growths, varying in size from a pea to an egg. 
They vary from a tumor the size of a pea to an enormous growth. 
Hunter removed, after death, a tumor that weighed 145 pounds, 
while the woman weighed but 95 pounds. 

How much the gro\^rth of myomata is influenced by the 
activity of the sexual organs remains difficult to determine, 
but the fact that myomata originate and have their greatest 
growth during the years most favorable for procreation can not 
be without significance. Myomata occur with about equal fre- 
quency in the married and unmarried. Observation does not 
justify us in the assertion that the size to which they attain or 



652 GYNECOLOGY. 

the rapidity of their growth is influenced by the married or the 
single state. Some regard sterility as a cause of myomata, 
others as a consequence. 

Winckel and Schroder consider that the following conclusions 
are justified: 

1. Fibroid growths originate without relation to marriage or 
to pregnancy. 

2. Sexual excitement favors growth. 

3. The presence of a growth inclines to prevent child-bearing. 

4. Pregnancy promotes growth. 

585. Pathologic Anatomy. — Whatever the origin, they are 
found in either the bod}^ or the cervix of the uterus, but in 
larger proportion in the former situation, and more frequently 
in its posterior wall. 

The consistence of the growth varies with its structure. 
A soft muscular mass presents, upon section, a reddish-pink 
color, with wavy, glistening bands running in every direction, 
but with a tendency to form whorls about individual centers, 
owing to the origin of the disorder along the course of blood- 
vessels. The cut surface of a fresh section presents an uneven 
appearance, owing to the elasticity of the fibrous tissue causing 
the softer muscle surfaces to bulge. The mass is enveloped 
by a false capsule, produced by compression changes in the 
uterine structure. The capsule varies in thickness according 
to the site of its development. If the growth has originated 
in the middle layer, the capsule is thick and well formed; 
but if immediately beneath the peritoneum or the mucous 
membrane, the capsule will be very thin or may even be 
absent. 

About the tumor is a layer of loose connective tissue which 
permits ready enucleation. Occasionally, there are numerous 
fibrous bands to the capsule, which render enucleation difficult, 
and are so frequent as to appear like a hyperplasia. 

The tumor is surrounded by numerous large vessels, from 
which it is nourished, but which do not penetrate its substance 
to any great depth. 

The vascularity of the structure is slight as compared to 
that of the uterine wall, for well-formed vessels are rarely found 
away from the circumference. In the softer variety the blood- 
vessels are comparatively numerous; in the harder varieties 
they are very scant. 

586. Microscopic Appearance. — The comparative amount of 
muscular and connective tissues varies widely. In young 
and rapidly growing tumors the muscular tissue predominates 
and the capsule or line of demarcation between growth and 
uterus is ill defined. As the tumor becomes older and more 



GENITAL TUMORS. 653 

mature, there is a substitution of connective for muscular 
tissue, and it becomes hard and dense. (Fig. 461.) The 
section differs in appearance according to its direction. A 
longitudinal section presents cells of an elongated shape with 
rod-like nuclei, while a transverse section resembles groups 
of round cells. Occasionally, between the muscle bundles 
are spores — lymph-glands lined with endothelium. They 
develop from cellular proliferation about the capillaries, and, 
with increase of connective tissue, may grow to large size. (Fig.. 
462.) 









' ' , ' ' - '^ 




/ 


■••■) 




V 


/ 


', 


/ ■ » ; 






f- 1 




. / 







^ .^ 






Fig. 461. — Microscopic Section; Myoma Uteri. — {Coplin.) 

587. Varieties. — Bishop follows Gusserow's classification and 
divides myomata into the multiple and encapsulated and the 
single and nonencapsulated. The former are found most largely 
in the body of the uterus, while the latter grow from the cervix. 
This division is based upon structure. The multiple growths are 
hard and firm. They largely consist of fibrous tissue, apparently 
mature, and no longer continue to grow. They are also called 
fibromata. The single growth is soft and elastic. It is largely 
supplied with vessels and is rapid in growth. In its structures the 



654 



GYNECOLOGY. 



muscular tissue will be found to predominate. They are known 
as liomyomata or fibromyomata. All myomata originate within 
the uterine wall, but upon their proximity to its inner or outer 
surface will depend their future progress. The most frequent 
classification, and that which we find most useful in practice, 
is a division of myomatous growths according to their situation 
into: (i) Submucous, intramural, or concentric (capsulated, non- 
encapsulated) ; (2) interstitial, mural, or centric; (3) subperito- 
neal, extramural, or excentric (capsulated and nonencapsulated) ; 
and (4) fibromyomata of the cervix. 

Degenerative changes which may occur in the life-history 
of such a growth are indicated by the terms edematous, col- 
loid or myxomatous, 
fibrocystic, calcific, 
necrobiotic, necrotic ; 
but these changes are 
not sufficiently con- 
stant to justify their 
employment to indi- 
cate a distinct classifi- 
cation. 

The same state- 
ment can also be ap- 
plied to the further 
division which is 
sometimes given: sar- 
comatous, adenomyo- 
matous, telangiectatic, 
ly mphangiectatic . 

588. Submucous 
fibroids, according to 
the proximity of their 
origin to the mucous 
surface, present two 
varieties — the encapsulated and the nonencapsulated or free. The 
former develop in the wall and are extruded beneath the mucous 
membrane by the uterine contractions. The second variety, the 
free, originate immediately beneath the internal surface, and 
are not supplied with a capsule, but are closely enveloped by 
the mucosa. An encapsulated tumor may become free through 
absorption or thinning of its capsule from pressure. 

The encapsulated variety is much larger than the free. 
Nature regards such growths as foreign bodies and endeavors 
to extrude them from the uterine walls. Under this action 
a submucous fibroid may become pedunculated, when it is 
known as a submucous or fibroid polypus. (Fig. 463.) The 




Fig. 462. — Liomyoma of the Uterus 
^ in. obj.; i in. oc. 



B. and L. 



GENITAL TUMORS. 



655 



muscular capsule may resist expulsion and prevent peduncula- 
tion, while the tumor bulges into the uterine cavity from a 
more or less broad base, and is called a sessile submucous 
fibroid, (^ig. 464.) 

The sessile and pedunculated submucous tumors enlarge 
the organ and increase its vascularity. (Fig. 465.) The re- 
peated contractions, together with the expulsive efforts, lead 
to hypertrophy of the muscle-wall to such a degree as to simu- 




Fig. 463. — Submucous Myoma (Polypoid), 



late pregnancy. The circulation in the entire mucous mem- 
brane, and especially in that portion covering the tumor, be- 
comes obstructed, leading to severe hemorrhages. 

The severe pressure frequently causes atrophy and ulcera- 
tion in the free variety, and the production of grave secondary 
changes, such as sloughing and gangrene. Compression of 
the neck of a polypus may cause edema, and, when acute, can 
produce gangrene or sloughing of the mass, and a fatal termina- 



656 



GYNECOLOGY. 




Fig. 464. — Sessile Submucous Myoma. 




Fig. 465. — Submucous Myoma Occupying Uterine Cavity. 



GENITAL TUMORS. 



657 



tion. In the slower form the chronic edema may often be 
mistaken for a cyst. Uterine contraction may lead to elongation 
of the pedicle of a pedunculated fibroid and cause its extrusion 
from the external os into the vagina, where it can be readily 
recognized and removed. (Fig. 466.) The elongation of the 
pedicle may become sufficient to permit the mass to hang from 
the vulva. The expulsion into the vagina may be sudden, 
but it generally occurs slowly. Very rapid expulsion of a tumor 
with a short pedicle may produce partial or complete inversion. 
Not infrequently the polypus may be felt projecting from the 
OS during menstruation, w^hile it disappears during the intervals ; 
this condition is knoAvn as intermittent polypus. 




Fig. 466. — Submucous Myoma Extruded into the Vagina. 



Rarely by the efforts of the uterus the tumor may be com- 
pletely and spontaneously separated and extruded. 

The pressure of the uterine or vaginal wall upon the tumor 
sometimes causes ulceration, from which adhesions may form 
and by which the nutrition is maintained. A polypus may be 
so firmly gripped by the cervix, as to cut off its supply of nu- 
trition and cause it to slough. The gangrene may spread up- 
ward and produce a fatal result. Such a condition can easily 
be mistaken for cancer. 

589. Interstitial, mural, or centric fibroid growths develop 
in the parenchyma of the uterus, frequently attain to enor- 
mous size, and involve the entire structure of the uterus, when 

42 



658 



GYNECOLOGY. 



they are then known as the diffuse or the gigantic fibroid. (Fig. 
467.) A second variety is the circumscribed general form 
(Fig. 468) ; the third, the local interstitial fibroid. (Fig. 469.) 
In the general circumscribed variety, as described by Schroder, 
the wall of the uterus may be filled by a large number of growths. 
In the localized fibroma a single or two or three interstitial 
fibromata may be found. These growths are situated in the 
wall of the organ, surrounded by muscle-fibers and the loose 
connective-tissue capsule, from which they can be readily 
enucleated. In the diffuse form the entire structure of the 
uterus seems to be taken up by the grow^th, and it is difficult 
to fix a sharp border of limitation between the growth and 




Fig. 467. — Voluminous Myomata Occupying Anterior and Posterior Walls. 



the uterine wall. These growths, when they attain a large 
size, not infrequently draw out the lower portion of the uterus 
as a pedicle, which may be attenuated to the' thickness of the 
finger and twisted, as seen in one case by Kiister, where, in 
the twist, the torsion was two and one-half times. The cer- 
vical canal had been obliterated. Occasionally, the uterine 
body is found separated from the cervix. The muscular struc- 
ture of the uterus itself undergoes hypertrophy in these cases, 
particiilarly when but few growths occupy the wall. The 
uterine wall becomes thickened, its cavity is increased, and 
the cavity undergoes various changes in its shape and size. 



GENITAL TUMORS. 



659 




Fig. 468. — Circumscribed Interstitial Myomata 




Fig. 469. — Local Interstitial Myomata. 



660 



GYNECOLOGY. 



according to the development of the tumor and its projection 
into it. (Fig. 470.) The influence of the growth upon the 
endometrium is most marked.- In a large interstitial myoma 
it may become strongly distended, not infrequently thin and 
atrophied. (Figs. 471 and 472.) In other cases there is a hyper- 
trophy of the entire mucous membrane, occasionally only of the 
glands; in others, the interstitial tissue between them is in- 
creased. (Fig. 473.) Occasionally, the condition is complicated 
by malignant edema. In the great majority of cases hypertrophy 
of the mucous membrane is found associated with these growths. 




Fig. 470. — Uterus Opened, Showing Multiple Interstitial Myomata. 



(Fig. 474.) Indeed, the endometrium may be three or four times 
its normal thickness. 

590. Subperitoneal growths (also called subserous, eccentric, 
or extramural) are generally spheric or ovoid masses springing 
from the external surface by a more or less distinctly marked 
pedicle. Like the submucous, these growths are sessile or 
pedunculated. While the latter class are polypi, that term 
is more generally applied to intra-uterine growths. 

The surface of the growth may be smooth or irregular, 
according to the contraction of the connective tissue. A division 
into free and encapsulated is made: the former covered by 



GENITAL TUMORS. 



661 




Fig. 471. — Sectioned Surface of Uterus, Showing Several Fibroid Tumors: a, 
Uterine cavity; b, large subserous fibroid. 




Fig. 472. — Serous Surface of Same Specimen: a, Cervix 



662 



GYNECOLOGY. 



the serous layer, which is closely attached, without capsule, 
to the surface of the tumor; the latter, or encapsulated, are 
covered with a layer of muscle -wall beneath the peritoneum. 

The free are hard and only attain a small size; the encap- 
sulated are soft and often become enormous. The pedicle 
of the tumor varies in length and thickness. It may be short, 
thick, and permit but little movement between the tumor 
and the uterus, or long and attenuated, affording such marked 
freedom as to cause doubt whether the growth is connected 
with the uterus. The pedicle can sometimes become so twisted 




Fig. 473. — Uterus Incised, Containing Interstitial Fibromyomata: a, a, Tumors; 

b, uterine cavit3\ 



as to cut off the circulation of the tumor and lead to its loss 
of vitality, the development of gangrene, and subsequently to 
septicemia or peritonitis ; or the tumor, in more fortunate cases, 
may become adherent to the surrounding viscera and lose its 
association with the uterus. Such a growth is nourished by 
its adhesions. Not infrequently a very movable tumor causes 
ascites, and thus simulates a malignant growth. 

591. Fibromyoma of the Cervix. — Cervical myomata, like 
those of the uterine body, are submucous, interstitial, and sub- 
serous. These growths originate in the body of the organ, 



GENITAL TUMORS. 



663 



and, by the process of enucleation through contraction, may 
have been driven downward, either through the cervical canal 
or into its structure by splitting it externally or, as in the single 
noncapsulated tumor, had its origin in the cervix and grown 
either upward or^ downward. The latter may be either pedun- 
culated or sessile, and rarely attain a size larger than a goose- 
egg, although they may completely fill the pelvis. (Fig. 476.) 
They cause contraction and prolapse of the uterus, and simu- 




Fig. 474. — ^Uterus Incised, Showing General Circumscribed Fibromyomata : 

Uterine cavity. 



late inversion of the organ. They may be divided into two 
classes : 

(A) Those of the external os, in which the tumor is formed 
by a cylindric or elongated lip in the interstitial variety. (Fig. 
477.) The submucous growths of the cervical canal are oc- 
casionally polypoid, which, like slender stalactites, descend 
through the cervix by the splitting process. 

,(-B) Tumors from the sub vaginal portion. These are more 



664 



GYNECOLOGY. 



important when developed from the external surface and situated 
between the layers of the pelvic floor. They become intra- 
ligamentary and exceedingly dangerous by pressure upon the 
ureter or upon the pelvic vessels; also when posteriorly they 
press upon the rectum and push the uterus forward and up- 
ward. Occasionally, the tumor crowds anteriorly against the 
bladder, between it and the uterus. Most generally these 
tumors are found surrounded by a loose capsule, which permits 
of ready enucleation.' Sometimes, however, there is no line 
of demarcation between the tumor and the uterine structure. 
592. Etiology. — These gro^\i;hs occur more frequently than 
any other to which women are subject. Not infrequently 
they may attain to considerable size without the patient being 




Fig. 475. — Subserous Myomata. 



aware of their existence, and are then recognized only by ac- 
cident. The causes of their development are unknown. Reck- 
linghausen attributed their origin to embryonic tissue, the 
remains of the Wolffian bodies. The irritation which char- 
acterizes fibromata is not a physiologic irritation, like that of 
pregnancy, but a diseased impetus. It is an unusual kind 
of local irritation, associated with a weak or debilitated con- 
dition of the concerned spot. This introduces Cohnheim's 
view of tumor origin, which was that the local irritation was 
brought to development by the presence of tumor germs. The 
influence of sexual irritation is appreciated, in that statistics 
demonstrate that in the majority of cases the first indications 



GENITAL TUMORS. 



665 



appear during the second half of the third decad: i. e., between 
the twentieth and thirtieth years. The tumor forms in the 
first half of the fourth decad, shortly after the thirtieth year. 
These growths rarely develop before or after these periods, 
although Biegel is, reported to have seen one in a girl ten years 
of age, and Leopold the beginning of a myoma in a child. There 
has been much discussion as to the influence of the married or 
single state upon the development of these growths. The in- 
vestigations of Moller show that 32.8 per cent, occur in virgins, 
67.2 per cent, in those who are not, but one-half of the latter 
are sterile. Hofmeier says that the number of births does 




Fig. 476. — Pedunculated Myoma of the Cervix. 



not stand in any relation to the causal formation of the growth, 
while Winckel believes that the married are more predisposed, 
and that the myomatous formation decreases the number of 
births. Shoemacher, on the contrary, asserted that the un- 
married are more frequently so diseased. Hofmeier accounts 
for the relatively large number of unmarried women who suffer 
from myomata by the explanation that the tumor formation 
is one of the few causes which lead them to consult the gyne- 
cologist. Prochownik gives syphilitic infection as a cause, 
but the growths occur so frequently in individuals in whom 
there has been no possibility of such infection as to render 



666 



GYNECOLOGY. 



this view of little value. Olshausen and Gusserow assigned 
local irritation as the etiologic factor. Shoemacher also looks 
upon menstrual congestion as a cause, but to give these reasons 
for the development of the disease is equivalent to giving none, 
as it is necessary to seek further for the cause of the irritation. 
Moller, already referred to, frequently found that a myoma 
the size of a pin's head was separated from the uterine muscle 
by a distinct layer of connective tissue. Small arteries could 
be traced into the growths, which still retained their three 
coats ; consequently he doubted the theory that myomata arise 
from the muscular coat of the blood-vessels. The cause is 




Fig. 477. — Sessile Myoma of the Cervix, 



sometimes considered as congenital. The influence of heredity, 
as to whether there is a predisposition to the development 
of such growths in families, may be questioned. Heredity 
seems to be manifested in the greater apparent and comparative 
susceptibility of the colored race to the development of fibroid 
growths. It is not unusual to find several members of one family 
suffering from myomata. Among the various causes it is 
probable that sexual irritation should have the first place, 
and this irritation may have been engendered without the 
uterus having undergone the changes incident to pregnancy 
and labor. The abnormal irritation may be the result of mas- 



GENITAL TUMORS. 667 

turbation, of psychic disturbances, of such unnatural processes 
as the evasion of maternity, of the psychic phenomena engen- 
dered by body-contact with man, of sexual agitation, and of 
other factors which may produce repeated injurious influence. 
It is quite possible that defective development or an abnormal 
position of the uterus may exert a marked influence in the 
development of these growths. • Mann reports a childless widow 
at the age of forty-three, twice married, who had never men- 
struated, and for ten years had had a large fibromyoma. It 
still remains evident, however, that in any individual myoma 
we can not positively assign a cause which can be considered 
a definite reason for its development. 

593. Symptoms. — The symptoms which lead us to suspect 
the existence of myomata are: Hemorrhage, pain, and abdom- 
inal cramp, especially when associated with progressive enlarge- 
ment of the abdomen. The symptoms of the individual case 
will depend largely upon the variety of tumor present. In 
the subperitoneal and in the interstitial, which have not en- 
croached upon the uterine mucous membrane, the growth 
may attain to considerable size without the manifestation 
of any symptoms which would attract the attention of the 
patient. Not infrequently, especially in the unmarried, such 
growths attain to a size so great as to be remarked by the friends 
of the patient, before she is herself aware of its existence. The 
growth will be suspected when the patient has a history of a 
slow but progressive enlargement of the lower half of the ab- 
domen. Not infrequently one of the first symptoms will be 
inability of the patient properly to evacuate her urine. In- 
deed, there may be even complete retention, which will re- 
quire the aid of the physician to secure relief, during which 
the presence of the tumor may be for the first time recognized. 
It may, in such a case, be situated in the pelvis, completely 
filling it and pushing the uterus above it. If the growth simply 
presses against the bladder, it may only slightly interfere with 
the evacuation, or, which is more likely, cause frequent mic- 
turition, because of the inability of the bladder to distend. 
Urination may be so painful and so frequent as to lead the 
patient and her physician to suppose that an inflammation 
of the bladder exists. Such a growth may press upon the 
rectum, causing constipation, retention of gas, tympanitic 
abdomen, interference with the circulation in the lower portion 
of the rectum, the occurrence of hemorrhoids, prolapse, marked 
anal pruritus, or burning of the anus, the existence of a fissure, 
and not infrequently the veins of the anus as well as those of 
the vulva become exceedingly varicose. Such a growth, be- 
coming incarcerated in the pelvis, may cause severe pressure 



668 GYNECOLOGY. 

on the surrounding structures, with sloughing and gangrene of the 
pelvic soft parts. (Fig, 479.) An intraligamentary tumor may 
push the uterus to the opposite side, and the organ may be so 
small compared with the tumor that its situation is with difficulty 
determined. (Fig. 480.) Pressure of the tumor on the pelvic 
nerves may produce pain extending down the posterior sur- 
face of the leg in the form of sciatica or a crural neuralgia over 
the front of the leg, or marked pain in the sacrum. While 
these symptoms may occur in any form of myoma, they are, 
however, characteristic of the subperitoneal and interstitial 
varieties, especially when the latter has not encroached upon 
the mucous membrane. In the interstitial growth, which 
grows toward the mucous membrane, giving rise to obstruction 
in its circulation and leading to engorgement and degeneration 
of the overlying mucosa, hemorrhage is a marked symptom. 
In the submucous varieties bleeding is a more or less constant 
and characteristic symptom. Hemorrhage may be manifested 
by an increase of the menstrual flow (menorrhagia) or an ir- 
regular bleeding (metrorrhagia) may result. Hemorrhage, as 
before stated, is a very prominent symptom of all submucous 
growths. The bleeding varies, and is not affected by the size 
of the gro^i:h, since a small polypoid growth will very frequently 
cause just as severe hemorrhage, if not greater than that 
which occurs from a large tumor. In these growths the menses 
become profuse and prolonged, resulting in marked anemia 
and great debility. The bleeding may be continuous and 
very free for a few days, then a period of brown secretion, to 
be again followed by profuse bleeding. Blood may be dis- 
charged as a bright fluid blood or in large clots. Clotting has 
no significance, and depends upon the size of the uterine cavity 
in which the accumulation occurs, or it may take place in the 
vagina; pedunculated polypi may be associated with severe 
flooding. Intermenstrual hemorrhage may alternate with 
periods of amenorrhea, which may continue for months, and 
when the patient is congratulating herself that she has recovered, 
another severe hemorrhage occurs. The bleeding occurs from 
two sources: (i) From the covering mucosa of the tumor; (2) 
from the general uterine surface. The former is the active 
primary site of bleeding and is very vascular, particularly 
in the free variety. In some of the smaller groAvths the tumor 
will be found to be quite anemic. In these the hemorrhage 
is undoubtedly due to the irritation of the circumjacent uterine 
mucosa and the production of an interstitial endometritis. 
Metrorrhagia from rupture of veins in the superimposed mucosa 
is frequently associated with a profuse watery discharge, which 
adds to the depression and prevents the patient from regaining 
her health. 



GENITAL TUMORS. 669 

Leukorrhea, or discharge other than blood, is increased 
during the development of these grow^ths. The extrusion of 
the groT\i:h into the uterine cavity increases the normal watery 
discharge from the uterine glands. The interference with the 
circulation and the consequent hypertrophy of the glandular 
tissue cause a profuse secretion. This may be truly glandular 
in character and mixed with the desquamated epithelium. 
Pus-cells and blood-cells may also be found, according to the 
degenerative processes, which sooner or later ensue. As the 
cervix becomes dilated, its glands add their thick, viscid secre- 
tion to the abundant discharge. The partial or complete ex- 
trusion of the growth influences its circulation, not infrequently 
causing necrosis of portions of its surface or even the entire 
structure, according to the extent of the constriction. The 
discharge is often bloody, purulent, or watery, contains necrotic 
masses of detritus, and produces an extremely offensive odor. 
The patient, and not infrequently her attendant, has cause 
to suspect the existence of malignant disease. 

In all varieties of the tumor the blood supply of the growth 
itself is very slight, as no large vessels directly enter the tumor. 
Where the neoplasm is of some size, this deficient blood supply 
must affect the nutrition of its structure, and causes the pro- 
duction of toxins which have a deleterious influence upon the 
health of the individual. This is evident from the appearance of 
such patients where hemorrhage and leukorrheal discharge are 
not a factor. It is probable that these toxins have an influence 
upon the heart muscle and other structures of the body, causing 
conditions which are so frequenth' found associated with the 
presence of fibroid growths. It is probable that in these tox- 
ins will be found the explanation for the mental disturbance that 
is so frequently associated with the development of such growths 
and which usually clears up with their removal. It may also 
explain the occurrence of ascites which frequently is associated 
with subperitoneal gro^^^hs. 

Pain is not a constant symptom. It is frequently more 
a sensation of weight or pressure in the pelvis and upon the 
surrounding organs. Intense pain may characterize very small 
growths, but is conditioned somewhat upon their situation. 
K growth pedunculated or so situated upon the uterine wall 
that it projects into the internal os may act as a ball- valve, 
and be the cause of the most agonizing labor-like pains. I 
have seen this form of dysmenorrhea in many cases. (Fig. 478.) 
In one patient it was so severe as to require the administration 
of two grains of morphin at each menstrual period to render 
it endurable. Xn operation subsequently revealed that the 
patient had a double vagina and a bicornate uterus with two 



670 



GYNECOLOGY. 



distinct cervical canals in a common cervix. In one of these 
cavities was found a submucous tumor which, by a nipple- 
like projection, filled up the internal os, and explained the 
violence of the dysmenorrhea from which this patient had suf- 
fered. 

Sterility is a common SA^mptom and conception is the ex- 
ception. The inflammatory changes consequent upon the pres- 
ence of the growth render it unfavorable for the reception 
and retention of the fecundated ovum. More frequently than 
is generally appreciated, the tubes have undergone secondary 
changes which result in the occlusion of their abdominal ex- 
tremities, and thev are found to form retention cvsts. Further- 




Fig. 478. — Bicomate Uterus. Both Cornua Containing Myomata. 



more, pathologic conditions of the ovaries are sometimes found, 
and this fact, also, is not given the consideration it merits. Con- 
stipation, hemorrhoids, anal fissure, prolapse, and pain arising 
from pressure upon the rectum are more or less constant symp- 
toms and signs. Vesical tenesmus, cysts, frequent micturition, 
retention of urine, dilated ureter, and hydronephrosis are pro- 
duced by disturbance and obstruction of the urinary organs. 
Not infrequently the first symptom which leads to the discovery 
of the growth is the retention of urine, from pressure upon 
the vesical neck. The myomata may also be the cause of 
retention of urine from pressure upon the ureters interfering 
with the entrance of the secretion into the bladder, and, as a 
consequence, we may have renal dilatation even to the extent 
of sacculation of the kidneys. In one of my early operations 



GENITAL TUMORS. 671 

for myoma, upon a patient who had carried a large tumor for 
some twenty years, death occurred very shortly after the opera- 
tion. The autopsy revealed that both kidneys were distended, 
forming thin-walled sacs, that the ureters were several times their 
normal size, and 'that their walls had become greatly thinned. 
The protracted hemorrhages, profuse discharge, severe labor- 
like pain, and pressure upon the neighboring viscera are prone 
to result in a profound anemia, which is characterized by a 
straw-colored appearance of the skin, often so marked as to 
simulate cachexia and plainly indicate the gravity of the pa- 
tient's condition. 

594. Diagnosis of Myomata. — The existence of a fibroid growth 
of the uterus may be suspected when there is a slow but progres- 
sive enlargement of the lower part of the abdomen. It may occur 
in either the single or married woman, and need not be associated 
with any special indication of ill health. The physician should 
have in mind the possibility of its existence in every patient 
who consults him regarding a sensation of weight or pressure 
in the pelvis, disturbance of urination, such as frequent mic- 
turition, difficulty in evacuating the urine, or even sudden 
attacks of severe retention, which may necessitate the use of a 
catheter. Indeed, in every such case the condition of the 
pelvic viscera should be examined preliminary or subsequent 
to the use of the instrument. Uterine growths should be still 
further suspected if the patient is complaining of hemorrhoids, 
fissure of the anus, frequent bleeding from the bowel, pain 
and distress during, and difficulty in, defecation. The surgeon 
should never be misled into subjecting a patient to operation 
or treatment for hemorrhoids until he has examined the con- 
dition of the uterus. Only recently I was asked to operate 
upon a Sister of Charity for severe hemorrhoids, when examina- 
tion of the pelvic cavity revealed a group of subperitoneal and 
interstitial fibroids completely filling up the pelvis, the ex- 
istence of which she had never suspected. Profuse menstrual 
flow or irregular bloody discharge occurring in an unmarried 
woman or in one who does not give a history of the interruption 
of a recent pregnancy or abortion should lead to the suspicion 
of the existence of a submucous fibroid growth, particularly 
where this hemorrhage is associated with pain, often of labor- 
like character, as if the uterus were making an effort to expel 
a foreign body. This hemorrhage will often produce a marked 
anemia without emaciation, which distinguishes it from that 
associated with malignant disease. It should be remembered 
that no characteristic symptoms of myomata occur, and, there- 
fore, the physician is forced to rely for diagnosis and confirma- 
tion of his suspicions upon the physical signs. An important 



672 GYNECOLOGY. 

factor in this recognition is the consistence of the tumor or tumors 
in contrast with the surrounding soft structure of the unin- 
volved portions of the uterus, which permits the determination 
and dehmitation of the growth. The alterations in the shape 
of the uterus, according to the situation of the tumor, are of 
interest. A good-sized gro\A^h may fill out the organ and 
give it a spherical shape. The further contraction of the uterus 
forces the mass into the cervix, where it may distend the en- 
tire organ and be palpable at the external os. An intra-uterine 
polypus is determined only by palpation through the cervical 
canal. If the os is sufficiently open, the pedunculation can be 
inferred by the mobility, and definitely determined by reaching 
the pedicle with the finger. In small fibroid growths with a 
long pedicle the growth may be felt through the uterine walls 
to move under the pressure of the finger, even though the cervix 
is undilated. During the menstrual period with profuse menor- 
rhagia, the offending growth is frequently extruded or the 
cervical canal is sufficiently dilated to permit its recognition 
by the examining finger. A growth- may be extruded during 
the flow and drawn back in the interval, producing what is 
known as an intermittent polypus. A growth filling up the 
pelvis may make pressure upon the large vessels and so interfere 
with the return circulation of the lower extremities as to pro- 
duce enlargement of the superficial veins in compensation for 
the obstructed abdominal vessels. Pressure upon the ureters 
causes dilatation of these ducts, hydronephrosis, dilatation 
of the pelvis of the kidney, not infrequently a sacculation of 
the kidneys with destruction of the secreting tissue, the forma- 
tion of renal calculi, and even the occurrence of suppurative 
changes. These are characterized by more or less pain and 
discomfort in the region of the kidney — so much so as possibly to 
mask the pelvic lesion. Interference with the cardiac or renal 
functions causes profound anemia and the appearance of cach- 
exia, not infrequently interference with the veins of the lower 
extremities, phlegmasia, blocking of important vessels by 
particles of coagulated tissue, and possibly the formation of 
pulmonary and cerebral emboli. The diagnosis is determined 
by the bimanual examination, the introduction of one or two 
fingers into the vagina or the finger into the rectum, and the 
other hand over the abdomen. In this way the uterus is care- 
fully palpated and any enlargement of its structure recognized. 
If such enlargement or hardening of the organ exists, its size, 
relation to the organ, and its resistance are carefully studied. 
The fibroid growth has a definite shape, is smooth in outline, 
is well defined, and has a characteristic resistance. It is im- 
portant in the study of such growths to arrive at a diagnosis 



GENITAL TUMORS. 673 

not only as to the existence of fibroid, but also as to the character 
of growth which may be present. The decision, then, is made 
whether the growth is an intra-uterine or a submucous tumor. 
The endeavor is made to ascertain by palpating the cervix, 
when patulous, as* to whether the growth is a sessile or polypoid 
tumor. If the uterus is occupied by interstitial growths, their 
situation is determined, whether they occupy the anterior or pos- 
terior wall or the fundus; if subperitoneal, from what portion 
of the organ they spring. The latter growths are divided into 
three types: (i) When the growth proceeds from the fundus 
or the anterior wall, grows upward and in the progress of develop- 
ment becomes pedunculated ; (2) whether it is pushed out through 
the lateral wall of the uterus between the folds of the broad 
ligament, practically splitting and spreading this out and dis- 




Fig. 479. — Intraligamentary Myoma. 

placing the uterus to the opposite side (Fig. 479); (3) when it 
grows downward from the posterior wall and is beneath the 
peritoneum, but probably not even in contact with it. When 
the tumor is small and as yet nonpedunculated, it may be difficult 
to determine by conjoined manipulation from which wall it has 
originated. This can be accomplished either by the intro- 
duction of the sound into the uterus or, better, by the dilatation 
of the organ and the introduction of the finger. With one 
finger in the uterus and the hand over the abdomen or a finger 
in the rectum, the physician is enabled accurately to determine 
the relation of the growths to the uterine wall. The factor 
which should be fixed in mind as an essential one for the recog- 
nition of fibroid growths is their smooth, regular outline. In 
the fibromyomata of the cervix the tumor presents a mass which 
43 



674 GYNECOLOGY. 

is situated in the vagina, not infrequently filling it, is quite 
movable, and between it and the vaginal walls the finger can 
be easily passed. Its situation external to the cervix pre- 
cludes the probability of it having undergone necrosis from 
pressure, but occasionally inflammation may be developed in 
the vagina from the pressure of the growth, which will lead to 
agglutination between the tumor surface and the vaginal wall. 
The attachment of the tumor is recognized by bimanual pal- 
pation with traction upon the tumor. 

595. Differential Diagnosis of Myomata. — An accurate diag- 
nosis of any condition is secured only b}^ carefully reviewing 
the conditions with which it may be confused. The conditions 
with which myomata are likely to be confounded are: 

Normal pregnancy. 

Extra-uterine pregnancy. 

Desmoid tumor of abdominal walls. 

Inversion. 

Carcinoma. 

Sarcoma. 

Incomplete abortion. 

Subinvolution with endometritis. 

Uterine displacements. 

Ovarian displacements. 

Ovarian cysts. 

Pelvic infiltrations. 

Sactosalpinx. 

Floating kidney. 

Normal Pregnancy. — The amenorrhea, subjective symptoms, 
regular growth of the uterus, absence of hardness in its walls, 
and a sensation of elasticity are generally sufficient to determine 
the diagnosis of pregnancy. We have already seen that a 
limited amenorrhea may be characterized by a submucous 
myoma, and a patient may go for months without a hemor- 
rhage. On the other hand, hemorrhage may occasionally com- 
plicate the early months of pregnancy. I formerly attended 
a patient who always suspected herself pregnant if the menstrual 
flow was especially free, and she continued to menstruate for 
two or three months following the occurrence of each preg- 
nancy. The myomata may be present as small, edematous, 
subperitoneal nodules, which may be mistaken for the extremities 
of the fetus. Calcification of a fibroid has led to the growth 
being mistaken for the fetal head. The existence of the tumor 
does not preclude the possibility of pregnancy as a complication. 
The occurrence of pregnancy associated with fibroids should be 
suspected when the growth takes on more rapid enlargement, 
when the rapidity of the growth is greater than that which 



GENITAL TUMORS. 675 

usually characterizes a fibroid tumor, and when a portion of 
the mass presents a sensation of elasticity. The regular shape, 
size, and outline of the uterus under the bimanual, with the 
contractions of the pregnant organ, which are absent in the 
nonpregnant, contrasted with the more or less firm resistance, 
the irregular enlargement, and the smooth nodular outline, 
should establish the diagnosis. In diagnosis the following case 
very graphically illustrates, as shown in Figs. 489 and 490, that 
fibroid tumors under certain conditions may simulate pregnancy. 
The patient, about forty-two years of age, had applied to her 
physician because of an uncomfortable sensation attended 
with enlargement of the lower portion of the abdomen. On 
examination, he pronounced her pregnant. This diagnosis 
was repeated by him after a subsequent examination, and 
coincided in by other physicians. She came under my obser- 
vation some length of time after having completed the supposed 
normal period of her pregnancy and was referred to me as a 
case of delayed labor. Upon examination, the cervix presented 
its normal size. Above it, in front, however, could be felt very 
distinctly two rounded masses with a sulcus between them, 
which was taken by the examiners to be a fontanelle. The 
abdomen was enlarged, about the size of a pregnancy at six 
months. There was a sensation of elasticity or rather of dis- 
tention in the abdomen. When pressure was made against it, a 
mass could be felt which was pushed back on deep pressure, and 
could be felt impinging against the abdominal wall when the 
hand was suddenly removed. This sensation was taken to be 
ballottement of the fetal body. Bimanual examination, however, 
convinced me that if this was a pregnancy, it was extra-uterine, 
as the mass could be felt too readity through the anterior vaginal 
wall to be within the uterine cavity. It was found that the 
woman continued to menstruate, that the enlargement had 
increased only to a ver}^ slight extent in the last few months. 
The investigation of the condition caused me to pronounce it one 
of multinodular myomata, one of which was a large mass with 
a rather thick pedicle, permitting it to be pushed away, but 
firm enough to bring it back against the abdominal wall, and 
thus produce the sensation of ballottement. .The freedom 
of movement was accounted for by the presence of free fluid 
in the peritoneal cavity. This diagnosis was confirmed by 
operation. 

Extra-uterine pregnancy will present symptoms in the early 
stage similar to those of a normal pregnancy, as amenorrhea, 
nausea, mammary changes, etc., associated with a history of 
colic -like pains on one or the other side of the pelvis, with later 
a marked tearing pain, possibly attended by fainting, and symp- 



676 GYNECOLOGY. 

toms of internal hemorrhage. Subsequently a mass will be 
found in the side or an increase in the size of the abdomen will 
take place, but this enlargement will be less symmetrical than 
is the case in a normal pregnancy. The examination of the 
patient will ordinarily reveal the uterus slightly enlarged, some- 
what softened, free from any irregular or nodular masses, pos- 
sibly displaced to one side, or crowded forward by a mass which 
is situated in the side of the pelvis or in Douglas' pouch pos- 
terior to the uterus. In the advanced stages the parts of the 
fetus may be felt, probably with greater ease than if the fetus 
was contained within the uterus. 

Desmoid tumor of the abdominal walls presents the same hard- 
ness and resistance as does a fibroid growth of the uterus, but de- 
veloping in the muscular structure of the abdomen it generally 
becomes by its weight more or less pendulous and usually does 
not attain to large size, so is readily distinguished from the deeper 
seated uterine growths. In my clinic in the spring of 1905 a 
colored woman of thirty years, who had given birth to two children, 
presented herself with a distention of the abdomen which was 
quite symmetrical and extended from the pelvis to beneath the 
ribs. Palpation disclosed a firm, hard mass, occupying the entire 
abdomen and quite movable. The diagnosis was made of intersti- 
tial uterine myoma and resort made to operation. Incision in 
the median line, however, exposed the tumor as continuous with 
the abdominal wall, and did not afford access to the peritoneal 
cavity until it had been carried some distance above the umbili- 
cus. The growth sprang from the right side of the abdominal 
wall, was covered upon its inner surface with peritoneum, and 
had no association with the uterus. (See Fig. 480.) The tumor 
weighed nineteen pounds. (Fig. 481.) Notwithstanding that 
this growth grew inward from the under surface of the muscular 
walls and filled the abdominal cavity, careful bimanual examina- 
tion should have revealed that it had no connection with the 
uterus and that the abdominal walls could not be moved over it. 

Incomplete Abortion. — The uterus may be larger than nor- 
mal and the patient give a history of irregularity and more or less 
continuous bloody discharge from the uterus. Careful question- 
ing will afford a history of amenorrhea and belief of the patient 
that she has been pregnant. The uterus will be large, softened, 
and when the cervix is patulous, the finger can be introduced, re- 
vealing the enclosed embryonic tissue. 

Inversion. — Inversion of the uterus may be associated with 
a myoma with a short pedicle, attached near to the uterine 
fundus. The efforts at extrusion of such a mass, after dilatation 
of the cervical canal, may cause a dragging upon the fundus 
and gradual inversion. A polypus with a moderately thick 



GENITAL TUMORS. 



677 




Fig. 480.— Large Desmoid Tumor of Abdominal Wall Weighing, upon Removal, 
Nineteen and One-half Pounds. 

a, Adipose tissue of abdominal wall; h, b, recti muscles from which tumor orig- 
inated; c, aponeurotic sheath of recti muscles; d, portion of tumor projecting 
downward into pelvic cavity. 



678 



GYNECOLOGY. 



pedicle, when extruded from the os, may be distinguished from 
the body of an inverted litems " with difficulty. A myoma is 
said to be less sensitive than the uterus, but this is not sufficiently 
characteristic to be of much value in diagnosis. The inverted 
uterus shows upon inspection the orifice of the tube upon either 
side. In each condition the neck of the uterus can be felt 
encircling the pedicle of the tumor like a cuff. The diagnosis 
is best established by introducing a finger into the rectum, while 
traction is made upon the tumor. In case of inversion the 
cup-shaped cavity of the inverted uterus will be felt, where in 
ordinary cases the uterine fundus should be situated. The 
exercise of recto-abdominal touch, while traction is made upon 




Fig. 481. — Histologic Section of Desmoid Tumor. 

a, Blood-vessel; b, area of specimen showing edema; c, long spindle-shaped 

cells; note scarcity of nuclei. 



the protruding mass, will afford an unfailing method of deter- 
mining the diagnosis. A sound passed into the uterus in a 
case of a cervical tumor will be found to pass at one side the 
entire length of the ordinary uterus. In an inversion of the 
organ the sound will pass an equal distance on all sides of the 
tumor. The diagnosis, ordinarily, however, can be accom- 
plished without the use of the sound. 

Carcinoma and Sarcoma. — Profuse bleeding, pain, and dis- 
charge are common to both fibroid tumors and malignant dis- 
eases of the uterus. In the majority of cases the offensive 
discharge associated with malignant disease is not found in 



GENITAL TUMORS. 679 

myomata. The recognition of this fact has sometimes led 
to error in judgment ; thus, in a case where a myomatous growth 
has pushed through the cervix, has been for a length of time 
constricted by it, caries or superficial necrosis follows as a re- 
sult of the interference with the circulation in the tumor, from 
which the careless observer may be led to a diagnosis of malignant 
disease. A digital examination of such a patient, however, 
reveals the fact that the vagina is occupied by a tumor which 
is firm in consistence, is smooth and regular in outline, is not 
friable nor easily broken down, and thus differs materially 
from the friable necrotic mass which is found in the vagina in 
the cauliflower growth of malignant disease. A sloughing 
fibroid within the uterine cavity may afford some difficulty 
in the diagnosis. It causes a thin, watery discharge, which 
is exceedingly offensive. It may have caused repeated attacks 
of hemorrhage. The associated loss of blood, with the absorp- 
tion of the products of decomposition from necrotic tissue, 
produces a condition of sapremia which is with difficulty differ- 
entiated from malignant disease. In such cases, however, 
the diagnosis is determined by dilatation of the uterine canal. 
The necrotic growth forms a large tumor, one which is more 
resistant, in which fragments broken away and examined pre- 
sent the regular lamellated structure of a fibroid growth, but 
nowhere is seen the nesting or collection of epithelial masses 
surrounded by a connective-tissue stroma pathognomonic of 
carcinoma or the homogeneous mass of cellular tissue with 
an absence of true blood-vessels which characterizes the sarcoma. 

Subinvolution iviih Endometritis. — Subinvolution is a chronic 
inflammation of the uterine parenchyma, and when it has existed 
for a length of time, the uterus becomes firm and hard, indis- 
tinguishable from the hardness of myomata. The enlargement 
of the uterus is uniform, involving the cervix as well,, Avhile in 
fibroid growths the enlargement is pronounced only in that part 
of the uterus which comprises the groA\i:h. 

Uterine Displacements. — Flexions of the uterus are the 
varieties of uterine displacements most readily confounded 
with fibroid groA\i:hs. Indeed, it should not be overlooked 
that a fibroid growth may be the cause of the displacement. 
The growth, by its smooth outline and situation, may form 
such an angle as to cause one to regard it as the fundus uteri. 
These are the cases in which the sound can be successfully 
employed to ascertain whether the direction of the uterine 
canal corresponds to the position of the tumor. The cases 
are rather few, however, in which the gynecologist can not 
accurately locate the fundus uteri and detect the relations of 
the growth thereto by practising the bimanual examination 



680 GYNECOLOGY. 

in association with the vagino -abdominal or recto-abdominal 
touch. Such an examination will reveal the greater consistence 
of the growth, its rounded, smooth outline, and the extent 
of its association with the uterus. In a flexion, when the organ 
is straightened between the internal and external fingers, the 
normal outline of the uterus is found restored. 

Displacements of the Ovary. — The ovary is likely to afford 
confusion of diagnosis only when it is firmly fixed to the uterus 
by inflammatory exudate or has become somewhat enlarged. 
Its situation, the inability to recognize the ovary in any other 
situation, and its extreme sensitiveness should reveal its true 
character. 

Ovarian Cyst.- — It is frequently difficult to differentiate be- 
tween a fibroid tumor with a long pedicle, which has become ede- 
matous, and an ovarian cyst of the glandular or dermoid variety. 
If the cervix is grasped with a double tenaculum, while an 
assistant, with the hand over the abdomen, draws up the tumor, 
we are enabled through a rectal examination to ascertain a 
more exact determination of the relation of the pedicle of the 
tumor to the uterus. This examination, with the patient 
under the influence of an anesthetic, will generally be sufficient 
to determine the diagnosis. It should not be forgotten, how- 
ever, that the existence of a fibroid tumor does not necessarily 
preclude the possibility of pregnancy, as we can have pregnancy 
complicating fibroid growths. I narrowly escaped operating 
some years ago upon a patient who had a history of having had a 
very profuse bleeding during the preceding three weeks. The 
right side of the uterus presented a gro^\^h, which was firm and 
hard, and was recognized as a fibroid. Upon the left side of the 
abdomen there was more sensation of elasticity or indistinct 
fluctuation, and it w^as believed that we had an areolar glandular 
ovarian growth closely adherent to a fibroid of the uterus. On 
the day set for the operation, on starting to cleanse the vagina, a 
foot and leg of a fetus were found projecting from the dilated os, 
and a partly macerated fetus was delivered. Upon removal of 
the placenta the uterus contracted and disclosed a pretty good- 
sized fibroid upon the right side of the uterus. The patient re- 
covered, and with marked decrease of the fibroid growth during 
the progress of involution, rendering operation for its removal 
unnecessary. 

Pelvic infiltrations are recognized by the previous history 
of inflammation and the irregular and undefined outline of 
the masses which are found. 

Sactosalpinx is usually preceded by a history of inflam- 
mation. The mass is felt at one side of, or posterior to, the 
uterus. When adherent to the latter, the connection is so 
irregular and undefined as to reveal its character. 



GENITAL TUMORS. 



681 



Floating kidney forms a tumor which is generally situated 
at a higher level. The fingers can be pushed between it and 
the symphysis and the promontory of the sacrum, and both can 
be palpated below the supposed growth. This would be impos- 
sible in a growth .connected with the uterus. The floating kid- 
ney can generally be pushed back into its normal situation. 




Fig. 482. — Myoma Uteri with Large Intraligamentary Fibromata. 
a, Anterior and posterior leaflets of broad ligament; h, tumor. 



596. Alterations and Degenerations. — During the active prog- 
ress of a myoma it becomes larger, sw^ollen, and more ede- 
matous as each menstrual period approaches; and, following 
the flow, it decreases in size and becomes more firm and re- 
sistant. In the submucous and interstitial varieties cessation 
of the menstrual function or the establishment of the climacteric 
is delayed for from five to ten years longer than would occur in a 



682 , GYNECOLOGY. 

woman whose uterus was free from disease. With the establish- 
ment of the menopause, however, the growth usually diminishes 
in size and undergoes a process of atrophy. The gro^1:h be- 
comes firm and hard, and its size remains fixed ; or it may become 
soft, and, with this, a process of metabolism follows, by which the 
gro^vth gradually disappears. In small growths the same length 
of time after the climacteric the tumor may have almost entirely 
vanished. These changes also occasionally take place during 
the progress of a pregnancy or in nonpuerperal cases without our 
being able to assign a cause. Not infrequently a patient has been 
alarmed at the discovery, through examination, of the presence 
of a fibroid growth, and some months or years later another in- 
vestigation reveals no indication of its existence. If the second 
investigation has been made by another physician, he may be 
inclined to believe that a misrepresentation had been made, and 
yet do an injustice in giving expression to such a suspicion. 

Edema. — Edema of large fibroids, especially of the inter- 
stitial variety, is not infrequent. The condition is caused by con- 
striction or torsion of the pedicle, through which the venous cir- 
culation is obstructed, while the arteries continue to pump in 
the blood. The decreased circulation in such growths may result 
in edema as a first stage of a necrobiosis. The interstices of the 
tumor become filled with serous fluid, so that the enlarged growth 
gives a sensation of indistinct fluctuation or elasticity, so marked 
that only the determination of the continuation of the growth 
with the cervix renders one able to difterentiate it from an 
areolar glandular ovarian cyst. After the removal of such a 
growth an incision into its wall will permit the discharge of a 
large quantity of serous fluid. I once extirpated the uterus for 
such a growth, when a prominent surgeon examining it asserted 
that it was a fibrocystic tumor. An incision through the struc- 
ture, however, failed to reveal a single cyst, while nearly a 
gallon of fluid drained out of the growth in the two hours fol- 
lowing its removal and incision. 

Fibrocystic tumors (Fig. 483) result from dilatation of the 
lymph-spaces in the tumor, from degeneration of a portion of its 
structure and the formation of a cavity, or possibly, in rare cases, 
from the separation of the structure of the tumor in edema. 

Calcification. — As the tumor matures its direct circulation is 
reduced and nutrition reaches its structures largely by transuda- 
tion. Under certain unknown chemical conditions of the blood 
this fluid is heavily charged with lime salts which are deposited 
within and upon the surface of the tumor, causing it to become 
enveloped in a stony shell or to form a calcareous mass. Lime 
salts were formerly administered to favor such formation and thus 
arrest further growth in myomatous tumors, but it was soon rec- 



GENITAL TUMORS. 



683 



ognized that other and more vital tissues of the body were 
equally vulnerable to such deposits. In the examination of 
gro^^i:hs which have undergone such change, the sensation given 
of pressure against bone renders such a tumor harder and more 
resistant than th$ ordinary mature fibroids. Not infrequently 
plates of bone will be felt to break beneath the palpating finger. 
Undoubtedly the cases reported of the expulsion of uterine cal- 
culi were myomata which had undergone this calcareous change. 
A submucous or interstitial fibroid so changed may subsequently 




Fig. 483 > — Fibrocystic Tumor of the Uterus. 



be expelled by the uterine contractions. Amyloid degeneration 
has been reported in one patient. Fatty degeneration has been 
evident from the macroscopic appearance of tumors I have re- 
moved, although it has been asserted that fatty degeneration 
of such growths is never confirmed by the microscope. 

Colloid Myxomatous Degeneration. — This condition, accord- 
ing to Virchow, is an effusion of mucous fluid between the mus- 
cular bands. The presence of a mucin proliferation of the 



684 



GYNECOLOGY. 



nuclei and small round cells permits of its being distinguished 
from simple edema. 

Inflammation, Suppuration, and Gangrene. — Inflammation 
of a growth may result from injury, traumatism, compression 
or obliteration of nutritive vessels of the tumor, and from septic 
infection following an exploration. Septic inflammation may 
follow an exploration or the delivery of a patient. The rapid 
changes which take place subsequent to the delivery of a patient 
who is suffering from a large fibroid may result in interference 
with its nutrition and in the development of inflammation 
and suppuration. Suppuration may take place external to the 
capsule, in the cellular tissue about it, or in the structure of 





Fig. 484. — Submucous Fibromyoma Undergoing Cystic Change. 



the tumor. This may have been preceded by mortification 
of a small part of an interstitial or a submucous growth. The 
gangrenous portions may be eliminated spontaneously, or may 
produce putrid infection. When a large growth has lost its 
vitality and is still retained within the wall of the uterus, it 
may gradually disintegrate, slough, and be expelled into the 
vagina through the cervix as a large sloughing mass, or may 
produce such marked symptoms from putrid infection that the 
life of the patient will be sacrificed notwithstanding operative 
interference for its removal. Such conditions are readily con- 
founded with malignant disease. Some years ago I saw a pa- 
tient who had been examined by a physician who assured 
her family that she was suffering from an incurable malignant 



GENITAL TUMORS. 



685 



growth, which must speedily terminate her life. The his- 
tory of profuse hemorrhage and of an exceedingly offensive 
discharge, and the appearance of profound anemia and a 
condition resembling cachexia, afforded apparent confirmation 
of the correctness of his suspicion. The finger disclosed a 
large mass filling the vagina, which, instead of being soft and 
friable, as a cauliflower gro\"s^h would be, was roughened on 




Fig. 485. — Myoma of the Body and Cancer of the Cervix. 



its inferior, but smooth upon its upper, surface, was quite mov- 
able, and a distinct pedicle could be recognized, which pro- 
jected from the cervical canal. The neck of the uterus was 
thin, pliable, and without any infiltrate, which demonstrated 
that the diagnosis of malignant disease was incorrect, and 
that the patient was suftering from a fibroid polypus whose sur- 
face was necrotic. In cases of doubt the history, more or less 



686 



GYNECOLOGY. 



firmness of the growth, the distinct arrangement of the struc- 
ture, even when gangrenous, and the absence of any cellular 
infiltrate are sufficient to afford a correct diagnosis. An abscess 
may develop either in the wall or within the gro^vth itself. 

Malignant Degeneration (Fig. 483). — Cancerous degeneration 
of a fibroid growth has not been demonstrated, nor is it easy to 
understand how it could occur, unless the gro\vth contains gland- 
ular tissue and is, consequently, a fibroid adenoma. The presence 
of the growth renders the uterus less resistant and facilitates 




Fig. 486. — Uterus Incised, Displaying Numerous Fibromyomatous Growths and 

Incipient Cancer of the Cervix. 

a, Shows invasion of cervix by cancer. 



the probability of malignant degeneration of the endometrium. 
The most frequent malignant degeneration, however, is the infil- 
tration of the fibroid growth by sarcomatous processes. 

597. Mixed Growths. — Enchondroma, Sarcoma, Osteoma, and 
Carcinoma. — The origin of these growths is uncertain. It 
is possible that they must originate in one of two ways — either 
in transformation of the cells which produce other tissue species, 
or in an invasion in which the growth is penetrated by the 
neighboring proliferating masses. Thus, we have myochon- 



GENITAL TUMORS. 687 

droma, myosarcoma, and myocarcinoma. The first of these 
is very rare. The second is less rare, and grows rapidly from 
a small invasion. The normal filamentous structure of the 
fibroid growth is soon lost in a homogeneous mass, which rapidly 
becomes necrotic; the tumor then forms a mere thick shell. 
With the necrosis of the mass, not infrequently vessels are 
eroded, and extensive hemorrhage may take place into the 
cavity. The disease is not confined to the growth, but invades 
the surrounding healthy tissues. The enveloping cells are 
large, irregular, rich in chromatin, and contain several nuclei. 
Sanger asserts that all myomatous growths containing irrita- 
tion cells are sarcomatous. 

Myocarcinoma arises from carcinomatous alteration of the 
surface of the polypus, or by development from the glandular 
constituents of an infiltrated adenomyoma. 

598. Complications. — The study of the progress of a fibroid 
growth from its origin in the wall of the uterus to its subsequent 
extrusion, and the changes and lesions to which it may be readily 
subjected, will aftbrd reasonable explanation for many com- 
plications which are associated with it and influence the prog- 
ress of the growth. Of these complications, the most im- 
portant, because one of the most frequent, is that of inflam- 
mation and the resulting adhesions. 

1. Inflammation, as we have already seen, may involve 
the structure of the growth or may influence only its super- 
ficial surface. The structure of the gro^^i:h can undergo in- 
flammation from decreased nutrition by its extrusion into 
the peritoneal cavity, when it becomes a foreign body, which 
nature, in its efforts to protect the general structure, surrounds 
with plastic material, from which the tumor may receive ad- 
ditional and necessary nutrition, and which fixes it in relation 
to the structures immediately about it. Such adhesions may 
take place with the intestine, the mesenter}^, or the abdominal 
wall, and may lead, through traction upon the tumor, to still 
further thinning or attenuation of its pedicle, and, finally, to 
separation from the body of the organ, so that occasionally such 
groT\i;hs are found removed from the original attachment and 
nourished through the inflammatory adhesions. The causes 
for inflam^matory changes may be divided into — (i ) those incident 
to alterations in the tumor; (2) to irritation changes in the 
peritoneum from the presence of the groT\i:h as a foreign body; 
(3) to infection. Infection may arise from disease of the ap- 
pendix, the Fallopian tubes, or through direct transmission 
from the intestinal cavity. 

2. Ascites. — A second, though less frequent, comphcation 
of my omat a is ascites. (Fig. 489.) This is attributed to invitation 



688 



GYNECOLOGY. 



of the peritoneum from pedunculated subperitoneal growths. 
(Fig. 490.) It is more probable that it may be engendered by 
the development of a toxin from lowered vitality in the growth 
which makes it a foreign body and causes irritation, which pro- 




Fig. 487. — Myoma Uteri Complicated by* Pyosalpinx, 

duces ascites. i\scites is much more frequent in malignant than 
in benign growths, and its presence should always awaken the 
suspicion that very grave changes are taking place in the growth. 
3. Disease of the Tithes (Fig. 487). — Disease of the Fallopian 
tubes as a complication of the presence of fibroid tumors is very 




Fig. 488. — Uterus Containing Several Fibroid Tumors Complicated by a Large 
Tubo-ovarian Cyst, a, a, Shows sites of fibromata ; b, round ligament. 



common. It may be a simple hydrosalpinx or a pyosalpinx. 
Adhesions may be extensive, and very greatly complicate any 
operative procedure. The most frequent cause of this condition 
is undoubtedly the result of infection which has traveled through 



GENITAL TUMORS, 



689 



the litems. The presence of the fibroid gro\\'ths favors the 
congestion of the pelvis, and makes the tubal mucous mem- 
brane a more favorable soil. Pressure of the growth upon 
a Fallopian tube may interfere with its circulation, cause a 
distention of its Ciavity, and the formation of a tubal collection. 
This defective drainage causes regurgitation into the pelvic perito- 




Fig. 489. — A Myoma Which, from the Associated Ascites, Had Been Mistaken 

for Pregnane V. 



netim from the abdominal end of the tube, which sets up a peri- 
toneal inflammation and produces a closure of the tube and 
the formation of a hydrosalpinx or pyosalpinx, according to 
the exposure to or absence of infection. 

5. Ovarian Hematoma. — The distention of the ovary by the 
accumulation of blood is not an unusual complication of myo- 
mata. The ovarian sac is usually adherent and filled with a 

44 



690 



GYNECOLOGY. 



thin, dark, bloody colored fluid. The sac wall is easily ruptured 
and is rarely dissected without rupture occurring. 

6. Pregnancy. — The presence of fibroid growths is a cause of 
sterility, but does not necessarily preclude the occurrence of 
pregnancy. The early recognition of the compHcation is of the 
very greatest importance, as the progress of the pregnancy may 
have a marked influence upon the rapidity of the growth, while 
the growth may favor the premature interruption of the course 
of pregnancy. This complication is of so much importance that 
it may be studied from various standpoints. 

599. (a) The Influence of the Myoma upon Conception. — 




Fig. 490. — Tumor Shown after Removal. 



It can be readily understood that the presence of a fibroid 
growth — for instance, of the polypoid or submucous character — 
renders the mucous membrane of the uterus unprepared for 
the retention of the fecundated ovum, and not infrequently 
the removal of a polypus from a woman who has been sterile 
for a number of years is very shortly followed by conception, 
even though years of sterility had preceded. The engorge- 
ment of the uterine mucosa, occasioned by the presence of a 
sessile submucous or of an interstitial growth, which encroaches 
upon the uterine canal, the profuse and irregular hemorrhages 
accompanying its progress, associated with the constant and 



GENITAL TUMORS. 



691 



excessive secretion from the glandular structure, present con- 
ditions exceedingly unfavorable for the fecundation of the ovum. 
600. (b) Influence of Pregnancy upon the Myoma. — The in- 
creased congestion of the uterus incident to pregnancy causes 
greater nutritioil of the growth, results not infrequently in its 
rapid increase in size, and the growth which was situated in the 
pelvis is of itself raised out of it, and forms a more formidable 
mass. In some cases the growth is slow, adhesions may so fix 
and bind down the uterus that it can not rise out of the pelvis, 
and we may have as a result an impaction of a mass in the 
pelvis similar to that which occurs in the gravid retroflexed uterus. 
Sometimes the rise of the growth in the pelvis may be rapid, or 




Fig. 491. — Myoma Complicated by Pregnancy. 



it may be situated low in the pelvis, and not emerge from it 
until between the sixth and seventh months. Intraligamentary 
growths become altered by the pressure and cause very marked 
distress. The fibroid polypus or submucous tumor is sometimes 
extruded into the vagina, whence it may be removed without 
any indication of interference with the pregnancy. Marked 
changes in size, form, and consistence of the uterine growth may 
be noticed. The increase in size is often due to edema. Venous 
engorgement frequently occurs as a result of obstruction of the 
veins, while the blood is continually poured into the structure by 
the less readily controlled arteries. (Fig. 490.) Where a num- 
ber of fibroid growths are situated together in the pelvis, they not 



692 



GYNECOLOGY. 



infrequently become nonpedunculated subserous growths, and 
often become flattened from pressure. The circulation can be 
obstructed to such a degree as to result in necrotic changes. 
Such changes require early and prompt interference in order to 
save the life of the patient. 

60 1, (c) The Influence of the Myoma upon Pregnancy. — An 
intra -uterine growth, covered as it is by mucous membrane, pre- 




Fig. 492. — Uterus Containing Large Fibroid Tumor and Three Months' Fetus. 



disposes the subject to increased bleeding. This hemorrhage and 
the changes in the uterine mucous membrane may be so marked 
as to result in premature interruption of pregnancy ; or the ovum 
may be lodged low in the uterine cavity, causing the formation 
of the placenta over the cervix, — w^hat is known as placenta 
prasvia, — in which the life of the mother will become more 
endangered as the pregnancy progresses. The situation of the 
tumor may favor retroversion of the gravid uterus and its im- 



GENITAL TUMORS. 693 

paction in the pelvis, or the tumor itself may be impacted with 
the development of the pregnancy. The presence of a fibroid 
growth, with its pressure upon the tubes, may cause the develop- 
ment of a tubal pregnancy, which may remain unsuspected until 
its rupture into 'the abdominal cavity occurs, with the accom- 
panying peril to the patient. 

602. (<i) Influence upon Labor. — In the majority of small 
fibroid growths, especially those which have not attained to a 
size larger than a walnut or an orange, the presence of the growth 
produces but slight, if any, influence upon the progress of the 
labor. Tumors of a larger size, which are situated in the pelvis, 
may interfere with labor and require operative interference for 
their previous removal. Occasionally, with changed position of 
the patient and elevation of the hips, the tumor may be pressed 
out of the pelvis, or a tumor situated low in the pelvis, under 
the dilatation of the os and elevation of the cervix as the dilata- 
tion progresses, may be lifted out of the pelvis. Interstitial and 
subserous growths, with a broad base, cause irregular and in- 
effective uterine contractions, which affect the progress of labor. 
The existence of myomata has been found to compHcate greatly 
the results. Winckel, comparing the statistics of one hundred 
and forty-seven cases of labor complicated with myomata with 
those suffering from contracted pelves, said 5 to 6 per cent, of 
parturients with contracted pelves perish during labor, but when 
complicated with myomata, 50 per cent, succumb. The infantile 
mortality is often more serious. Nauss found the infantile mor- 
tality to be 66 per cent. Lefour, in three hundred cases ob- 
served, gives 77 per cent. Large subserous growths, when above 
the pelvis, in or near the fundus of the uterus, exert no influence 
upon the progress of the labor. Cervical growths, however, are 
very important, as from their situation they may occupy a 
position below the level of the cervix, and necessarity' interfere 
with the delivery of the fetus, but even when the growth is thus 
found in the pelvis, it is often spontaneously raised as the process 
of dilatation proceeds. Submucous growths may be extruded 
into the vagina previous to the inception of labor and then be 
removed. If the tumor becomes edematous, it is more com- 
pressible and less of an obstacle to the progress of .delivery. 

603. Course and Prognosis. — Many of these growths, espe- 
cially when small, produce very few symptoms, and those quite 
vague. Others cause serious disturbance until the occurrence of 
the menopause, after which the great majority of tumors undergo 
atrophy and diminish by induration during the process of in- 
volution. The process of atrophy is occasionally hastened by 
pregnancy, so that patients who have been recognized as suffering 
from a fibroid growth have the tumor entirely disappear by the 



694 GYNECOLOGY. 

completion of the pregnancy ; or, in other cases, during the sub- 
sequent convalescence. Occasionally, there is a marked breaking- 
down of the health, associated with fibrous cysts or fibromyomata, 
and particularly after the critical age. The tumors that remain 
quiescent are not necessarily small, but can reach to the level of 
the navel, so that the patient may be entirely ignorant of their 
presence and only be made aware of the existence of the growth 
by an examination that is made for some intercurrent condition, 
or for the treatment of symptoms produced by the tumor, of the 
cause of which the patient had previously been in ignorance. In 
the majority of cases the tumor does not threaten life either 
directly or indirectly. In this respect these growths are quite 
different from carcinoma or an ovarian tumor. The carcinoma 
demands immediate operation, as soon as discovered, for life is 
destroyed by its progress ; but in myomata such advice must be 
modified, for in many cases the growth is not even the cause of 
the disease for which the aid of the physician is sought. In 
others it may be productive of disturbance. In myomata of large 
size, which reach above the umbilicus in young individuals, the 
prognosis as to time is good, but there are possibilities of it 
becoming worse. In a w^oman who has not reached the age of 
thirty-five years, and a tumor attains a size corresponding to that 
of a pregnancy at full term, one can with security assert that the 
life of the individual is threatened, and the capacity for suffering 
must be limited. x\ttention should be directed to the symptoms 
that threaten life. The operation in such cases is no longer 
elective, but necessar3^ as the percentage of danger from the 
operation is more trifling than from the unfavorable influence 
produced by the growth of the tumor. In such cases, in order to 
produce conviction, the physician should be able to assert that the 
operation is advisable, and can not be postponed for ten or twenty 
years with the hope that the patient will still manifest good 
powers of resistance and a fair chance for recovery. If the 
tumor comes under observation at a later date, near the middle 
of the fifth decad, — about forty-three to forty-five years of age, — 
advice must be governed by the symptoms. It is possible that 
the tumor may swell during menstruation, and following its 
final cessation a more secure and much more considerable diminu- 
tion appears. In such cases the patient can be advised to wait 
until symptoms appear. In all cases the prognosis is dependent 
upon the age and its relation to the tumor. Great size of the 
tumor and its complex symptoms affect the future course. All 
complications that increase the size of the tumor render the 
prognosis the worse the younger the age of the patient. In 
these cases we have to determine that not the tumor but the com- 
plications are the cause. Complications that may be regarded as 



GENITAL TUMORS. 695 

hazardous in the young are less serious in the older, because the 
longer duration of the disease renders the organism more ac- 
customed to its existence. The prognosis is very bad in cases of 
severe heart affections, as fatty degeneration, though this is 
difficult to recognize in the living. Other complications may 
render the prognosis of the myomata bad, but not necessarily 
m.ake the prognosis of operation worse. The first indication 
of heart affection should be regarded as an indication for prompt 
operation. The prognosis is rendered much Avorse if the myoma 
has undergone a malignant degeneration, which, however, is 
rare. The rapid growth of the tumor is not necessarily an in- 
dication of malignant change, but more of cystic degeneration, 
which renders the prognosis of the further continuation of the 
growth worse, approaching in this respect the ovarian condition. 
The prognosis of all small tumors, especially those w^hich cause 
more or less hemorrhage, is not necessarily unfavorable. The 
danger is never so great as it appears to the patient. The dis- 
comfort produced by the condition and the anxiety about further 
duration and increase of bleeding impel the patient to consult 
her physician. In such cases it is difficult to arrive at a correct 
judgment, as the patients do not appreciate the fact that life 
is not necessarily threatened when menorrhagia is profuse. In 
the consideration of methods of treatment the fact must be kept 
in mind that the productive activity is injured, even though a 
bad prognosis is not to be asserted. The danger lies in the long 
duration of hemorrhage, which thereby renders worse the general 
condition. The prognosis is more grave when there is more 
marked general disturbance. In many cases the appearance 
of hemorrhage can be regarded as a favorable indication, as it 
proves that the spontaneous discharge of the tumor is taking 
place, following which the prognosis is improved. 

While it is true that a fibroid growth usually undergoes an 
abatement of its symptoms with the advent of the menopause, 
yet it should not be forgotten that the existence of such a growth 
generally delays the climacteric beyond the ordinary period of 
life at which it should occur. Occasionally, the natural evolution 
of a tumor, which results in its conversion into an extraperitoneal 
or intraperitoneal growth, may cause rupture of its pedicle, from 
the weight of the tumor alone or from thinnifig of the pedicle. 
By straining in defecation or in vomiting, a polypus may be ex- 
pelled. The rupture of a pedicle may limit the subsequent prog- 
ress of the growth, or it may remain grafted to the point where 
it has formed adhesions and be subsequently nourished, or it may 
lie free in the peritoneum and undergo mummification. A more 
serious spontaneous extrusion is mortification or gangrene of a 
tumor which has been expelled toward the uterine cavity. Per- 



696 GYNECOLOGY. 

foration of some of the neighboring organs may occur, as the 
bladder, the rectum, the rectovaginal pouch, or the abdominal 
wall. The two former conditions end in death; the latter, in 
possible recovery; or, finally, the tumor may be absorbed. 
Causes of death are profound anemia from repeated hemorrhage ; 
successive attacks of chronic peritonitis; disease of the kidneys; 
uremia and heart failure ; rupture of cyst ; or inflammation and 
gangrene. Sudden death has been observed as a result of em- 
bolism. Exploratory puncture favors the production of thrombi 
in the large venous sinuses. Death from shock after intravenous 
rupture has been reported. In very small growths which have 
been extruded beneath the peritoneum, and by their relations 
show no evidence of taking on growth, it is preferable that the 
patient should be left unaware of their existence. The various 
complications to which these growths are subject; the alterations 
which they may undergo during their progress; the influence 
upon the health of the individual from pressure upon important 
viscera; the danger from separation of growths and subsequent 
gangrene ; the possibility of their continued nutrition and growth 
subsequent to the menopause ; and the occasional malignant de- 
generation of the mass, associated with the diminished mortality 
by early operative procedure, particularly that of hysterectomy, 
would render it advisable that the extirpation of the growth 
should be practised. In the young the possibility of the occur- 
rence of pregnancy with its attendant dangers is an important 
factor, and one which may be an indication for treatment. 
When a woman possesses a condition which insures a maternal 
mortality of 50 per cent, and an infantile loss of 75 per cent, 
or over, it becomes a serious question whether she should be 
advised to marry, or, if married, should not be subjected to 
prompt operative interference. 

604. Treatment. — The mere discovery of the existence of a 
myoma must not be considered as a necessary indication 
for its removal, or even treatment. In this respect myomatous 
tumors differ from ovarian growths and from cancer, for the 
latter must be removed early, because its continued existence 
results in destructive influences upon the organism. The 
myoma must cause symptoms in order to indicate interference. 
The external relations of the patient must play a great role 
in the method of treatment — the capacity of resistance, the 
ability to undergo rest during menstruation, and to avoid severe 
bodily labor ; consequently the treatment is different in women 
of the working class, who can not rest, from that which must be 
practised in those who are able to take care of themselves. There 
are some cases in which hygienic and dietetic rules must govern. 
Neither the growth of the tumor nor the severity of the hemor- 



GENITAL TUMORS. 697 

rhage will necessarily be influenced by the methods of treat- 
ment; but by the avoidance of severe bodily effort and the 
promotion of nutrition disturbance of the health equilibrium 
is avoided. 

The patient, should be cautioned as to her manner of dress, 
and advised to wear loose clothing, since it would be exceed- 
ingly detrimental to force down into the lower part of the pelvis 
a myomatous uterus by wearing a tight corset. Tight clothing 
over an abdomen containing such growths may very readily 
produce inflammation which will lead to extensive and un- 
fortunate adhesions. When the abdominal wall has become 
greatly weakened by previous distention or the weight of a 
large tumor following the climacteric, the comfort of the pa- 
tient may be greatly enhanced by wearing a binder or support 
which will prevent the organ from falling forward. In such 
cases and in growths predisposed to the occurrence of torsion, 
a radical operation is indicated. Schroder attempted to fasten 
very movable tumors by sutures through the abdominal wall. 
Such a plan of treatment is not only unsatisfactory, but dangerous. 
The very profuse hemorrhage which frequently occurs requires 
that the nutrition should be carefully maintained and that 
all excesses of Bacchus and venery should be avoided. Pre- 
ceding and at the menstrual period the patient should be kept 
in bed and an ice-bladder or cold applications should be placed 
over the abdomen. Tea and coft'ee should be interdicted, be- 
cause experiments have demonstrated that both these articles 
increase the tendency to profuse bleeding. Various baths 
and mineral waters have been advocated as especially efficacious. 
Among these are the Kreuznach, Tolz, and Halle, in upper 
Austria, which are largely impregnated with iodin and bromin, 
and the Franzensbad and Elster, in which sulphur is an im- 
portant element. These waters probably exert their influence, 
not so much by their direct effect upon the tumor, as by 
the improvement of general nutrition. The health is built up, 
complete rest is secured, and the appetite is improved, and 
thus more or less relief is obtained. The treatment may be 
divided into: 

(a) Medical. 

(6) Electrical. 

(c) Surgical. 

605. (a) Medical Treatment. — The medical treatment should 
consist in the employment of remedies and hygienic measures 
directed to promote the general nutrition of the patient and 
to ameliorate the unpleasant symptoms. Such treatment must 
be largely symptomatic. The list of remedies advocated for 
the treatment of uterine myomata is very extensive; but, as 



698 GYNECOLOGY. 

is usually the case, the larger the list of remedial agents, the 
less beneficial the influence exerted. Notwithstanding the 
effective results that have been attributed to many different 
remedies, the history of myomatous growths discloses that they 
normally undergo peculiar changes, becoming sometimes larger 
and at others smaller. Occasionally the growth disappears 
without any assignable cause. Such fortunate results have 
added to the reputation of certain remedies , when similar con- 
ditions would probably have taken place had they not been 
administered. The agents which are most likely to exert an 
influence upon the progress of the growth are those which pro- 
duce an effect upon the muscular coat of the organ, and belong 
to that class known as oxytocics, of which ergot is the principal. 
Ergot may be administered by the stomach, by the rectum, 
or by hypodermatic injection. Its employment by the stomach 
causes more or less disturbance of the digestive tract, nausea, 
and vomiting. Moreover, in order to secure any beneficial 
effect from its employment, it must be continued over a long 
period of time, which renders this method of administration 
objectionable. Ergot in combination with a vegetable astringent 
will sometimes exert a favorable influence in decreasing and 
arresting a severe hemorrhage. It may be employed in the 
following combinations : 

R. Ext. ergot., . f5J 

Extract, hamamelis, 

Tinct. cinnamom aa f5ss. M. 

SiG. — f^j every two or three hours. 

Or: 

R . Ergotin, gr. ij 

Hydrastinin. hydrochlorat. , gr. i. M. 

Ft. capsulas No. xxx. 

SiG. — A capsule to be taken every three or four hours. 

The fluidextract of cotton-root or an extract of ustilago 
maidis, the ergot of corn, acts similarly to ergot, though to a 
less marked degree. When a patient suffers from expulsive 
efforts of the uterus, these may be ameliorated by the addition 
of extract of cannabis indica, gr. | to each dose. Ergot is most 
effective when administered by hypodermatic injection, using 
either the sterilized fluidextract, the normal liquid, or ergotin. 
The agent should be thoroughly aseptic, should be injected 
in close proximity to the tumor, preferably in the abdominal 
walls, and the caution should be taken to make the injections 
deeply into the muscle, since they will then be less likely to be 
the cause of abscess. Ergot acts in two ways: by stimulating 
the muscular coats of the blood-vessels, thus cutting off the 
supply of blood sent into the uterus ; and, secondly, by increasing 



GENITAL TUMORS. 699 

the activity of the muscular structure of the organ. Fibroid 
growths which are situated in the uterine wall are, by its in- 
fluence, more readily expelled, either intraperitoneally or extra- 
peritoneally. To be efficacious, the drug must be continued 
over a long period of time. When thus employed, it exerts an 
influence upon the muscular coat of the blood-vessels through- 
out the body, increases the danger of arterial sclerosis and the 
establishment of pathologic processes more serious than those 
for which the drug was administered. Among some of the 
drugs for which a reputation has been made by the retrogressive 
processes through which fibroids naturally pass may be named 
the potassium and ammonium salts, particularly the bromid, the 
iodid, and the chlorid of ammonium. How much influence 
any of these drugs will exert upon the progress of the disease 
is an undetermined question. Among other drugs that have 
been employed are sulphuric and gallic acids, turpentine, can- 
nabis indica, extract of hamamelis, extract of hydrastis can- 
adensis, and the active principles of the latter agent, hydrastin 
and hydrastinin. The latter agents exert a very favorable 
influence by constringing the blood-vessels, and thus serve to 
control hemorrhage. Efforts have been made to bring about 
the absorption or destruction of fibroid tumors to compensate 
for the deprivation of certain nutrient elements which enter 
largely into the composition of the growth. A diet composed 
of the carbohydrates seems to have been in some few cases effec- 
tive. Sir J. Y. Simpson, recognizing that the calcareous de- 
generation of a fibroid limited its further growth, purposed 
to accomplish this phenomenon by the administration of large 
doses of chlorid of calcium, but he soon found that this drug 
produced calcareous plates in the aorta and in the valves of the 
heart, and thus caused conditions much more grave than that 
for which it was given. In recent years the extract of thyroid 
gland has been advocated to reduce the size of growths and 
assist in the arrest of hemorrhage. As patients vary to a great 
degree in their susceptibility to the influence of this agent, it 
must, therefore, be employed carefully, increasing the dose 
gradually from three to five grains a day to the largest amount 
the sensibility of the patient will permit. In exophthalmic 
goiter, or in irritable conditions of the heart, the drug is badly 
borne, even in small doses. In some cases of fibroid growths 
in which I have employed it, the drug has produced such an 
effect upon the nervous system that its use had to be discon- 
tinued. Without question, it exerts an influence upon the 
lining structure of the uterus, and to this extent is beneficial in 
lessening the tendency to hemorrhage. Polk and Mann claim to 
have seen very pronounced effects from this drug in the dim- 



700 GYNECOLOGY. 

inution of the size of the tumor, but that it has any permanent 
influence is very questionable. Shober employed the mammary 
gland extract with apparent benefit in a limited number of 
cases, but the results do not seem to have given sufficient encour- 
agement to continue it. Probably the extract of the suprarenal 
gland or its active principle, adrenalin, is more effective than any 
of the other agents we have mentioned in stimulating the muscular 
coat of the blood-vessels, thus lessening the tendency to hemor- 
rhage. Various local measures have been employed, such as 
injections into the vagina. These, however, can have no in- 
fluence on hemorrhage from the uterus, as the coagulation of 
the blood in the vagina will be insufficient to afford any ob- 
struction to the severe uterine hemorrhage. Ice-water was 
formerly employed, later hot water. Both agents are efficacious 
in the field of obstetrics, but they have but little influence upon 
fibroid tumors. The agent must come directly in contact with 
the affected endometrium to be of any service. When hemor- 
rhage is very marked and uncontrollable and threatens the 
life of the patient, the vagina or even the uterine cavity may 
be packed with iodoform gauze, which acts as a tampon and 
thus controls the bleeding. When the uterine canal is opened, 
its cavity may be irrigated with hot w^ater or vinegar and water, 
or a solution of perchlorid of iron, tincture of iodin, and other 
agents for the purpose of arresting hemorrhage. These agents 
are sometimes quite effective for a length of time, but their 
use is not unattended with danger. The uterine canal should 
be so patulous that the subsequent drainage can be complete, 
but even in such cases the method of treatment is not infrequently 
attended with danger. I well remember a patient in my early 
experience who had a large fibroid tumor, which occasioned 
frequent attacks of profuse bleeding. The cervical cavity was 
quite patulous, and with a uterine syringe I injected tincture of 
iodin into its cavity. Almost before the syringe could be with- 
drawn the patient complained of tasting the drug, and within 
a few moments she had a most violent attack of pulmonary 
edema, which threatened her life, and from which she recovered 
only after a protracted illness. Moreover,- this state was followed 
by prolonged mental disturbance. Needless to say, I have 
not been inclined to regard this plan of treatment with a great 
deal of confidence. 

606. (b) Electric. — Electricity has been practised in the 
treatment of fibroid growths for many years. The methods 
of application of the agent were crude, and not infrequently 
were attended with great danger, especially when punctures 
were made through the abdominal wall directly into the tumor 
by an insulated needle, which thus produced a direct and localized 



GENITAL TUMORS. 701 

influence upon the structure immediately in contact with the 
poles. It remained for Apostoli, by his method of measuring 
the current and fixing the direct dosage, to evolve a plan of 
treatment which can be practised with a certain degree of pre- 
cision. Under ordinary means the passage of a current of 
from five to ten, or at most twenty milliamperes is attended 
with considerable discomfort. By his apparatus and method 
of procedure from loo to 200 milliamperes are employed. This 
is accomplished by the application over the external surface 
of a large, comparatively inactive electrode, while a more active 
electrode is introduced into the vagina, or, preferably, into 
the uterine cavity. He further defined the influence of the 
positive and negative poles. The positive pole was recognized 
as producing a decomposition of the fluids about it, which 
resulted in the accumulation there of an acid, while about 
the negative pole accumulated alkaline fluid. The former 
is the more destructive in its influence, and hence is more par- 
ticularly of value in diseased conditions of the mucous mem- 
brane which cause hemorrhage. The application of the posi- 
tive pole within the uterus causes an electrolytic or cauterizing 
action, which results in coagulation of the blood in the vessels 
and in the arrest of bleeding. The negative pole, on the other 
hand, by its influence produces edematous infiltration of the 
tissues at some distance from the pole, and the subsequent 
absorption decreases the size of the growth. For the practice 
of Apostoli 's treatment, then, are required: First, an electric 
battery sufficiently large to give a current strength of from 
200 to 300 milliamperes without its wearing out too rapidly; 
second, a galvanometer capable of measuring 500 milliamperes; 
third, a rheostat, by which the strength of the current can 
be gradually increased. The current-chooser — an instrument 
by which the current can be changed from positive to negative 
without the removal of electrodes — is important. It must 
be kept in mind in the use of this instrument, however, that 
the strength of the current must be very greatly reduced before 
such a change is made, as otherwise the patient would receive 
a violent and painful, if not a dangerous, shock. 

Electrodes. — The external electrode, to be placed over the 
abdomen, is of large size, and consists of the clay pad of Apostoli, 
of the bladder or water electrode, as advocated by Martin, or 
of a towel wet with a salt solution and over which the electrode 
is placed. The intra-uterine electrode consists of a probe in- 
sulated within a couple inches or more of its point, as may 
be desired. An ordinary probe with a gutta-percha hood which 
can be slid over it affords an efficient electrode. The electrodes 
are placed in position before the current is turned on. The 



702 GYNECOLOGY. 

latter is applied gradually, watching the galvanometer and the 
expression of the patient to ascertain the sensibility. The 
internal electrode is made of platinum or carbon, these agents 
having more endurance. As large quantities of strongly acid 
material accumulate about the electrode, the less durable metals 
would be very quickly destroyed by electrolytic action. In 
the application of electricity the vagina should be thoroughly 
cleaned in order that no infection shall be carried into the uterine 
cavity. It is recognized that electricity is a powerful anti- 
septic, but it is only in the stronger doses that it exerts such 
an influence. The application of electricity may be made 
two or three times a week, according to the intensity. When 
strong currents are used, but once a week is preferable. The 
seance lasts from five to fifteen minutes. Previous to the 
application of the external electrode the skin of the abdomen 
should be carefully examined for breaks in the corium, by 
denudation from scratching, or from the presence of furuncles. 
Any irritated points should be treated, and should be excluded 
from contact with the electrode by the application of collodion 
or pieces of plaster to insulate it. The external electrode is 
placed upon the abdomen and is connected with the battery; 
the internal electrode, also connected, is introduced, but with 
the precaution to have the current closed. The current is 
then opened slowly and carefully, and is gradually increased 
to the point of tolerance. The current is gradually reduced 
before the withdrawal of the electrode, to prevent the patient 
from being subjected to a severe shock. In the beginning of 
the treatment it is important that the current should be governed 
with the greatest care, and currents of moderate intensity 
only employed, until the degree of toleration is determined. 
It is difficult to fix the number of applications to be required — 
generally from twenty to thirty. 

Electro puncture of the Myoma. — Occasionally, the situation 
of the tumor may be such as greatly to displace the external 
OS and to render the canal tortuous and difficult for the intro- 
duction of the electrode. In such cases puncture may be made 
into the myoma through the anterior cervical wall. Just as 
rigid antisepsis should be practised for this procedure as for 
the most serious operation, and as it is not infrequently quite 
painful, an anesthetic should be employed. The puncture of 
the vagina is from one-half to one centimeter deep, and is per- 
formed without the employment of a speculum. Previous 
examination will disclose the position of the uterine artery, 
which should be avoided; also, care should be exercised not to 
injure the bladder or intestines. 



GENITAL TUMORS. 703 

Electricity exerts its influence in three ways: 

(a) In the diminution of the tumor from one-fifth to one- 
half of its original size. Complete disappearance is exceedingly 
rare. 

(b) In a most marked influence upon the hemorrhage. 

(c) In the relief of pain. 

The disappearance of pain and the arrest of hemorrhage 
necessarily result in the improvement of the general condition 
of the patient. Apostoli gives the following contraindications: 
First, hysteria; second, intestinal catarrh; third, pregnancy; 
fourth, malignant degeneration of the tumor; fifth, fibrocystic 
tumors. 

Some of his followers do not consider hysteria an absolute 
contraindication, but Apostoli has made the observation that 
the hysteric possess a very great intolerance to the electric 
current, making it impossible during the course of a sitting to 
introduce a sufliciently high current to bring about favorable 
results. In intestinal catarrh the current has a strong in- 
fluence on the solar plexus, which calls forth severe contraction 
of the intestinal muscle. It can be readily understood that 
the presence of malignant grow^ths must necessarily offer a 
direct contraindication to the electric treatment. The diag- 
nosis is sometimes difficult to determine. Kellogg has asserted 
that in a myoma which, after the menopause, shows a rapid 
growth, malignant degeneration is undoubtedly taking place, 
and that electric treatment should be withheld. In fibrocystic 
tumors the gas accumulation after the electric treatment may 
lead to suppuration. Gehrung, in order to avoid this, employs 
a puncture cannula, so that the fluid contents of the tumor 
can be drawn off. The presence of pus in the adnexa, as men- 
tioned by Apostoli, is a very frequent complication, and one 
often difficult to recognize. The employment of electricity 
in such cases is unexceptionally harmful. It is unnecessary 
that the inflammation should have gone on to suppuration in 
order to make the treatment objectionable. Very acute or 
subacute inflammation in the environment of the uterus is a 
positive contraindication to electrotherapeutics. 

Further, a very important contraindication for electric 
treatment depends upon the situation of the tumor and its 
relation to the uterus, and justifies the following statement: 

(a) In subserous tumors, particularly when they are pedun- 
culated, electric treatment will have but little beneficial effect, 
and is likely to prove injurious. 

(b) A pedunculated submucous fibroid affords no special 
advantages for electric treatment. 

In an inconsiderable number of cases suppuration of a poly- 



704 GYNECOLOGY. 

pus has resulted from intra-uterine electric treatment. Not 
infrequently has a fatal result appeared, or total extirpation 
of the suppurating organ been performed, with or without 
favorable result. Other contraindications, in addition to those 
named, are heart failure and acute nephritis. In very hard 
tumors the employment of electricity is opposed by Parsons, 
as they can not be influenced by it. 

Colossal Tumors. — In studying the influence of electricity 
upon the tissues we must take the polar and the interpolar. 

1. The Polar Influence. — This incidentally depends on the 
progress of electrolysis of the soft tissues. In the passage of 
the current from the metallic body, in fluid destruction which 
takes place in the salt solution, and about the positive pole 
an acid is formed, while the metal surrounds the negative. 
Similar changes occur in the tissues of the body, so that about 
the positive pole acid material, such as carbonic acid and chlo- 
rin, is set free. In the cathode watery material — the alkalies — 
are collected. It is asserted that these materials in the nascent 
state exert a strong chemic influence. Albumin is coagulated, 
the vessels are narrowed, and a hard, dry, brown-red slough 
occurs, while under longer employment the tissues are destroyed. 
About the negative pole a soft, succulent, glue-like, easily 
scraped-off white slough occurs, as if one had employed con- 
centrated caustic potash. Consecutive hemorrhages may follow 
the employment. The negative current is absorbent, and is 
much more painful than the positive. Investigations have 
demonstrated that the positive pole acts more on the cell germs 
or cellular tissue, and the negative upon the protoplasm. The 
latter is more diffuse, while the former has a sharper limita- 
tion. 

2. The Interpolar Method. — Apostoli's critics assert that 
the methods are not without danger. The principal dangers 
of myoma operations are hemorrhages and sepsis, but we have 
radical operations which present various series of dangers — 
embolus, pneumonia, ileus, and death from chloroform — with- 
out considering the later disturbances of nutrition. When we 
come to consider the advantages and disadvantages of electric 
treatment, we are led to the conclusion that it should be confined 
to the uncomplicated cases, while those cases which threaten 
life should be subjected to operative treatment. 

607. {c) Surgical. — The surgical treatment of fibroid growths 
may be either palliative or radical, but we will consider the 
procedures under the two divisions of vaginal and abdominal, 
according to the route by which the tumor is most accessible 
and may most readily be subjected to treatment. 



GENITAL TUMORS. 705 

The vaginal procedures consist in: 

1. Dilatation and curetment. 

2. Incision of the cervix. 

3. Incision of the capsule. 
4 Removal. 

(a) Torsion. 

(b) Incision of the pedicle. 

(c) Enucleation. 

(d) Morcellement. 

5. Ligation of the vessels. 

6. Hysterectomy. 

The abdominal route includes: 

7. Castration. 

8. Ligation of vessels. 

9. Myomectomy. 

10. Enucleation. 

11. Supravaginal amputation or partial hysterectomy. 

12. Panhysterectomy. 

Vaginal Procedures. 

608. (i) Dilatation and Curetment of the Uterus. — Dilatation 
of the uterus may be indicated as the first stage in treatment of 
the uterine growth or for the purpose of diagnosis. It may be 
accomplished by the mechanical dilators of Hegar, but without 
tearing the neck they will not afford sufficient dilatation of the 
cervix to permit the introduction of the finger. The preferable 
method of dilatation is the employment of a laminaria tent, and 
the vagina should be thoroughly cleansed and rendered as nearly 
aseptic as possible before its introduction. The os is exposed 
by a Sims speculum or perineal retractor. The cervix is seized 
with a double tenaculum, the os exposed, the plug of mucus 
filling the cervical cavity removed, and the canal thoroughly 
disinfected; then as large a tent is selected as can readily be 
introduced, or, when the canal is pretty well dilated., a nest of 
tents may be employed. Time can be saved by the introduction 
of several bougies preliminary to the insertion of tents. The 
larger number of tents which can thus be inserted permits the 
cervix to be so dilated by the first set of tents that the uterine 
cavity can be explored by the finger upon their removal. These 
tents previous to their insertion should be sterilized by heating, 
placed for a few minutes before their employment in a saturated 
solution of iodoform and ether in a mixture of equal parts of 
carbolic acid and alcohol, or, better still, in tincture of iodin. 
After the introduction of the tent iodoform gauze is placed be- 
neath it to protect the parts from infection and to keep the tent 
from being extruded. Usually, at the end of twelve hours the 
cavity will be sufficiently dilated to permit the introduction of 
the finger. If the dilatation is insufficient, the canal can be en- 
45 



706 



GYNECOLOGY. 



larged by the employment of Hegar's bougies or with a second 
series of tents. The exposure by dilatation permits the situation 




Fig. 493. — Incision of Cervix to Expose Intra-uterine Myoma. 



of the growth and its size and relations to be recognized. The 
curet is used in a manner similar to that described in the treat- 



GENITAL TUMORS. 



707 



merit for endometritis. It should be done thoroughly to remove 
the h^^pertrophied mucous membrane. This removal of the 
hypertrophied tissue ruptures and scrapes away the diseased 
vessels, and is effective in the arrest of hemorrhage. It should be 
followed by careful irrigation of the cavity, and subsequently by 
painting the canal with tincture of iodin or carbolic acid, or with a 




Fig. 494. — Cervix and Capsule Incised, the Latter Pushed Back. 



mixture of these two agents. When there is much hemorrhage 
following the use of the curet, the uterus should be packed with 
iodoform gauze. Curetment of the uterus, while effective in 
decreasing the hemorrhage, is not unattended with danger. The 
injury to the surface of the tumor may cause an inflammation, 
which will interfere with its nutrition, and, by the presence of 



708 GYNECOLOGY. 

germs which have been introduced during the procedure, may 
eventuate in suppuration and extensive necrosis. When the 
myomata project into the uterine canal and the latter is irregular, 
difficulty is experienced in reaching all points of the canal with 
the curet, and the plan of treatment will not be effectual. In 
small tumors that cause severe hemorrhage curetment is of no 
value, and nothing short of the removal of the tumor will be of 
service. Indeed, I question the wisdom of the employment of 
the curet in any submucous or interstitial tumor for hemorrhage, 
as the nutrition of the gro\\^h is likely to become so impaired 
with the processes of necrobiosis that its accompanying form- 
ation of toxins is engendered, which will certainly affect the 
general health of the individual. It is much better that the em- 
ployment of tents should be a preliminary to measures for the 
extirpation of the growth. 

609. (2) Incision of the Cervix. — This procedure is another 
palliative measure. (Fig. 493.) It consists in making a bilateral 
or an anteroposterior incision through the cervix, which dimin- 
ishes its resistance and facilitates the extrusion of the tumor. 
When the body of the uterus is well dilated by the growth, this 
procedure permits the tumor to be more rapidly extruded into 
the vagina, and it is thus rendered more accessible. It was 
formerly very generally practised as a preliminary to the adminis- 
tration of ergot, but not infrequently the rapid separation of the 
tumor thus induced led to gangrene or necrosis of the growth 
and to fatal infection of the patient. Incision of the cervix will 
frequently prove of value as a first step in operative procedure 
for the removal of a growth, and its employment should be limited 
to such instances. 

610. (3) Incision of the Capsule (Fig. 494). — In sessile sub- 
mucous or interstitial fibroids which project into the cavity of 
the uterus the more rapid expulsion of the tumor can be accom- 
plished by incising the uterine surface of the tumor into and 
through its capsule. The incision is accomplished by wrapping 
the blade of the knife with adhesive plaster at a necessary dis- 
tance from the point, as advocated by Atlee, or the thermo- 
cautery or galvanocautery knife can be employed. The wall is 
pushed back and the tumor partly enucleated, which decreases 
the resistance. Subsequent contraction promotes the extrusion 
of the tumor into the uterine cavity and renders it a pedunculated 
growth. This operation, though apparently but a slight one, is 
not free from danger, for the rapid extrusion which follows its 
performance not infrequently causes loss of vitality of the tumor 
and degenerative processes which may be dangerous to the life 
of the patient. The procedure is advisable only when it is em- 



GENITAL TUMORS. 



709 



ployed as one of the preliminary stages for the purpose of the 
removal of the groA\1:h. 

6ii. (4) Removal of the Growth. — (a) Torsion (Fig. 495). — 
When the growth is situated in the vagina, after Jiaving been 
extruded from the cavity of the uterus, and hangs by a pedicle, 
it can very readily be removed by torsion. The technic of the 
procedure consists in placing the patient in the dorsal position 
and exposing the tumor (after thorough asepsis) with an Ede- 
bohls speculum or with retractors. The growth is seized with a 
strong vulsellum forceps, preferably four-bladed, and turned 
upon its axis until the pedicle of the tumor is twisted off. When 




Fig. 495. — Removal of ]\Iyoma by Torsion of Its Pedicle. 



such forceps are not at hand, the same purpose can be accom- 
pHshed by seizing the tumor upon opposite sides with double 
tenacula and rotating it by traction with these instruments. 
When the tumor has not been extruded from the cervix, the os 
can be enlarged by a bilateral incision until the intra -uterine 
tumor is exposed, when it can be removed, if the tumor is pedun- 
culated, in the manner described. 

(6) Incision of the Pedicle. — When the tumor has been ex- 
truded from the uterine cavity, it may be seized and dragged 
upon with a pair of forceps until the finger can be passed over 
it as a guide, when with a pair of scissors (Fig. 496) the pedicle 
can be cut ; or the intra-uterine tumor can be rendered accessible 
by dilatation with tents, or through bilateral incision of the 



710 



GYNECOLOGY. 



cervix. The employment of the wire ecraseur or the galvano- 
cautery wire is by some advocated for the cutting of the pedicle, 
but any hemorrhage likely to occur can be controlled by gauze 
packing, and the procedure, outside of the possibility of lessened 
danger from hemorrhage, affords no advantage w^hich will com- 
pensate for the extra loss of time. In all these operations rigid 
asepsis must be practised. 

(c) Enucleation. — Enucleation was first practised upon sub- 
mucous fibroid growths of the sessile variety. Here, when the 
uterus is dilated, or after its dilatation, the tumor is exposed, 
seized with a pair of forceps, drawn upon, and, with the finger or 
a blunt dissector, the attachment to the uterus is broken and 




Fig. 496. — Incision of Pedicle of Myoma. 



the tumor removed. Thomas employed a serrated spoon which 
hugged closely to the surface of the tumor and pushed away the 
uterine wall. (Fig. 497.) This spoon, however, is not without 
danger in cases in w^hich the uterine wall overlying the tumor 
is thin. The enucleation can be as readily accomplished with 
a blunt dissector. The tumor should be rolled about during 
the procedure so that the surface to be separated is constantly 
under observation. When the tumor for enucleation is within 
the body of the uterus, the finger should be used as a guide. 
Interstitial tumors may also be removed in a similar way. 
If necessary, the cervix as a preliminary may be split by a 
bilateral incision through the internal os. An interstitial tumor 



GENITAL TUMORS. 



711 



of the anterior wall may be made accessible by a vertical inci- 
sion through the anterior lip until the base of the tumor is 
exposed, when it is seized and the tissue bluntly dissected 
way from it. (Fig. 498.) Occasionally, when the cervix is 
undilated and the tumor is in the anterior wall, it may be 
exposed by a transverse incision above the cervix, and subse- 
quently by a vertical cut at right angles to the former (Fig. 499) ; 
the flaps are turned back, after which the tumor is enucleated. 




Fig. 497. — Enucleation of Tumor through the Vagina. 



When necessary, the bladder should be dissected from the ante- 
rior surface of the uterus until the peritoneum is reached, and 
the latter can be opened. Retro-uterine tumors are made acces- 
sible through a posterior vaginal incision, which will permit the 
fundus to be rotated backward. Through this opening the enu- 
cleation is accomplished and the line of incision carefully closed 
by sutures before the organ is returned to its normal position. 
(Fig. 500.) 



712 



GYNECOLOGY. 



(d) Morcellement. — Not infrequently, as we proceed in the 
enucleation of these growths, it will be found that a tumor is so 
large jthat we are unable to complete our enucleation or to deliver 
the tumor through the vagina. In such cases the tumor may 
be reduced in size by the process described by the French as 
morcellement, which consists in cutting out sections of the mass 
with scissors or knife, and working up on one side until the tumor 
can be drawn down and the remaining portion completely enu- 




Fig. 498. — Interstitial Tumor Exposed by Vertical Incision of the Anterior Lip. 



cleated. It frequently can be accomplished by dividing the 
tumor into halves, quartering it, or cutting off small sections of 
the accessible portions with scissors or knife until the entire mass 
is removed. 

■The principle of morcellement is applied to the removal of 
theTuterus as well as to extirpation of morbid growths. The 
object is to insure the reduction of the size of the organ until it 



GENITAL TUMORS. 



713 



can readily pass through the vagina. It consists in splitting the 
cervix by vertical incision, then removing wedge-shaped masses 
from each side. Avoid nearer approach than one-half inch to the 




Fig. 499. — Myoma of Anterior Wall Exposed by Transverse and Vertical 

Incision. 



714 



GYNECOLOGY. 



lateral surfaces of the uterus. During the procedure the parts 
are made tense by traction upon the mass with a double tenacu- 
lum. (Fig. 501.) Care must be exercised to secure a new grip upon 
the remaining portion before any piece is excised. Upon the com- 
pletion of the delivery of the uterus, the hemostasis is accom- 
plished as in hysterectomy, which will be described later. After 
the removal of the growth by enucleation there will remain a 
considerable cavity, which is lined by tissue of low vitality. 




Fig. 500. — Myoma of Posterior Wall Exposed by Retro-uterine Incision, 



This should be thoroughly cleansed and loosely packed with 
iodoform gauze, and the patient watched that no renewal of 
bleeding occurs. The gauze packing prevents the accumulation 
of blood in the uterine cavity, keeps the surfaces apart, promotes 
the sealing of the surfaces by plastic exudate, and, by its presence 
as a foreign body, favors contraction of the remaining portion 
of the uterus. At the end of three days the gauze should be 
removed, the cavity thoroughly irrigated, and the uterus re- 



GENITAL TUMORS. 715 

packed, or a drainage-tube should be inserted, through which 
irrigation can subsequently be practised. When the cervix has 
been incised, the wound should be sutured as in an operation 
for lacerated cervix. All incisions, whether bilateral, through the 
anterior lip, or iii the wall of the uterus, should be closed by 
suture. 

612. (5) Ligation of the Vessels. — The usual observation that 
myomata decrease in size with the cessation of the periodic con- 
gestion of the uterus at the establishment of the menopause 



Fig. 501. — Removal of Myoma by Morcellement. 

induced Gottschalk and Martin to endeavor to decrease the 
blood-supply to such growths and thus avoid the necessity for 
sacrificing the function of procreation. Gottschalk was the 
pioneer in vaginal operations for this special purpose. He limits 
the operation to extraperitoneal tumors, and in seven years 
found but twenty cases in which it was applicable. Of sixteen 
of these, which continued under observation, decrease in pain and 
hemorrhage was experienced by the majority. In a few the 



716 GYNECOLOGY. 

good results were delayed. The treatment is as follows: The 
patient is placed in the lithotomy position, the uterus explored, 
and any submucous myomata removed, followed by cure ting as 
a routine measure. A circular incision in front of the cervix is 
prolonged as far as its posterior surface. The bladder is bluntly 
dissected from the uterus and broad ligaments and the vaginal 
mucosa loosened upon each side posterior to the broad ligament. 
The uterine artery and its branches are palpated and secured 
by three silk ligatures upon each side, which are cut short and 
buried by vaginal suture of the mucosa. The operation is fol- 
lowed by severe pains, and a few days later by a cast of the 
endometrium. In but three instances did the first menstruation 
occur at the normal period. Franklin Martin pursued the fol- 
lowing course: With the patient in the lithotomy position he 
dilated, cureted, irrigated the uterus with i : looo bichlorid 
solution, and loosely packed it with iodoform gauze. He pulled 
the cervix to one side, made a lateral curvilinear incision over 
each uterine artery, and pulled the bladder away from the ante- 
rior surface of the broad ligaments for over two inches, while the 
latter were partially isolated upon their posterior surfaces. The 
vessels were recognized and guarded by the finger, a ligature was 
passed upon each side, and the ends were cut short. Care had 
to be exercised that a ureter was not included in the ligature. 
He advised that in large tumors the broad ligament should still 
further be spread out and the ovarian artery upon one side 
seized and ligated. The ligated tissue was buried by suturing 
the vaginal mucosa, and the vagina was loosely packed with 
iodoform gauze. Both the vaginal and uterine packing were 
removed at the end of two days and bichlorid douches were 
subsequently employed. This confines the future blood supply 
of the tumor to one ovarian artery. Martin found that this 
plan of treatment resulted in arrest of hemorrhage and decrease 
in the size of the growth. The main objection to this plan of 
treatment is the possibility that in the ligation too much of 
the supply of blood may be cut off, and cause a loss of vitality 
and subsequent necrosis of the growth, which will greatly increase 
the danger to the patient. 

613. (6) Hysterectomy. — Removal of the uterus with the 
offending growths can be done with advantage through the 
vagina Avhen the latter is large and roomy and the uterus is 
not too large and freely movable. The operation should not 
be considered when the growth extends higher than midway 
to the umbilicus, when the broad ligaments are occupied by 
growths, or when the growths affect the nulliparous woman. 
There are two principal methods of operating: (i) The removal 
of the uterus without section, and (2) division of the organ in 



GENITAL TUMORS. 717 

order to reduce its bulk. The first procedure bears the name of 
Pean. His technic is as follows: The patient is placed in the 
lithotomy position, the cervix exposed with perineal and lateral 
retractors, seized Avith strong forceps, and a circular or oval in- 
cision carried thrpugh the vaginal mucosa nearer the os in front 
than behind. The finger or a blunt instrument separates the 
bladder from the uterus and broad ligaments. This procedure 
pushes the ureters out of the way. The posterior fornix, or 
Douglas' pouch, is opened in the same way. Freeing the uterus 
before and behind leaves it attached only by the broad ligaments. 
With the finger as a guide, a needle is made to transfix the 
broad ligament at about one-third its height and carry a ligature 
upon its withdrawal. The ligature is tied and the portion of 
structure under its control cut. Its repetition upon the opposite 
side permits the uterus to be drawm down, when a second series of 
sutures can be employed. This course soon permits the fundus 
to appear at the vulva, accompanied by the tubes and ovaries. 
When the uterus is removed, the ligatures upon both sides are 
temporarily left long, all bleeding vessels are secured, and the 
anterior and posterior flaps united by suture, securing them at 
either angle above the cut ends of the broad ligaments, or of the 
tube when the latter have been left. The ligatures are now cut 
short and the vagina loosely packed with gauze. By the second 
method, with section of the uterus. Landau, after exposing the 
cervix as described in the former operation, seizes it with a pair 
of vulsellum forceps at either angle of the os. The incisions of 
the vagina and of the bladder are accomplished as already de- 
scribed, when the anterior wall of the uterus is split in the median 
line with scissors, one blade of which enters the cervical canal, 
while steady traction is kept up upon the cervix. i\s the entire 
exposed surface is split, the finger is introduced and the bladder 
pushed away until the fundus appears. A fresh grip of the for- 
ceps is taken upon the sides of the incision ; the splitting may be 
carried over the fundus and dow^n from the posterior surface until 
the uterus is divided into tw^o portions. If the uterus is still too 
large for delivery, it can be still further divided or the growths 
may be enucleated. The broad ligament can be ligated from 
above downward or from below upward ; clamps maybe employed, 
though the}^ are not secure. Schauta lost seven -patients out of 
forty from the use of clamps. The most of the deaths were due 
to secondary hemorrhage following the removal of the clamps. 
The clamped portion of the ligament will become necrotic and 
may greatly delay convalescence. The wound is treated as 
in the previous procedure. Doyen modifies this operation 
by first opening the Douglas pouch and exploring the pelvic 
cavity. He next incises the anterior fornix, separates the blad- 



718 GYNECOLOGY. 

der, and crushes the lower and middle third of the broad ligament 
with a special angiotribe. The uterus is drawn down, anterior 
hemisection is performed by a median or V-shaped incision, and 
the fundus is drawn downward and forward. Pressure forceps 
are then applied to each broad ligament and the uterus removed. 
The upper part of the ligaments is crushed and tied with a 
silk ligature in the groove made by the angiotribe. The remain- 
ing portion of the wound is closed with catgut sutures. Should 
the uterus be too large, it can be reduced in size by morcellement, 
described in Section 537. Bishop cites eight hundred and thirty- 
six cases of vaginal hysterectomy with twenty-nine deaths, a 
mortality of 3.4 per cent. Some operators pride themselves on 
being able to remove per vagiham growths which extend to the 
umbilicus, but such a course is attended with so much increase 
of danger as to render it an unjustifiable method of procedure. 

Abdominal Route. 

614. (7) Castration. — As early as 1872 Hegar advocated the 
removal of the ovaries to establish premature menopause in order 
to accomplish reduction in the size of fibroid growths. This pro- 
cedure w^as devised in recognition of the fact that fibroid tumors 
generally decrease in size with the establishment of the climac- 
teric. The operation consists in the removal of the ovaries and 
tubes or the performance of oophorectomy. It was found, how- 
ever, that the removal of these organs was not infrequently 
attended with great difficulty, as the size of the growth led to a 
very vascular condition of the broad ligaments, and often the 
ovary was spread out upon the surface of the tumor, which ren- 
dered its enucleation and removal exceedingly difficult; some- 
times the tumor rotated in such a way as to carry one ovary 
posterior, rendering it absolutely inaccessible without reduction 
of the size of the tumor. Moreover, the ovary might be wedged 
between two multinodular growths, whence it could not be re- 
moved without injury to both. The procedure, unfortunately, 
was not always successful, as, indeed, many patients who were 
not victims of fibroid growth continued to menstruate or to have 
a bloody discharge subsequent to the removal of both ovaries. 
This is more probably due to the fact that the ovarian stroma ex- 
tends along the course of the ovarian ligament, and the removal 
of the mass in the ordinary method of procedure did not remove 
the entire ovarian structure. So long as any portion of it re- 
mained, to mature and throw off ova, just so long would bleeding 
from the uterus occur. Tait advised the entire removal of the 
Fallopian tubes as a sure method of establishing the climacteric, 
attributing the influence dominating menstruation to these organs. 
The advantage of this suggestion doubtless was that the ligature 



GENITAL TUMORS. 719 

was carried deeper and the ovarian artery ligated, which had 
escaped in a more superficial ligation. To insure the ligation of 
the artery it is generally recommended that the ligature should 
be placed sufficiently deep to include the round ligament. The 
advantage of cast^ration is that in typical cases it can be done in a 
very few minutes and with very slight danger ; but, unfortunately, 
in large fibroid growths the ovaries are not always typically 
situated. In every such operation, then, the first consideration 
should be to examine carefully the situation of the ovaries and the 
relation to the growth, and see whether both ovaries can be 
thoroughly removed. The removal of one would be powerless 
to exercise any influence on the progress of the growth or the 
correction of its abnormal symptoms. Occasionally, the tumor 
causes torsion of the uterus, by which one ovary is moved toward 
the front, and the other behind, the tumor in such a situation that 
it can not be reached ; or, as noted, the ovary can be so intimately 
connected with the surface of the tumor that any attempt to 
enucleate or remove it would be attended with more serious 
hemorrhage than would be occasioned by the removal of the 
growth. Another objection to the operation is that it does not 
always control the hemorrhage. In the performance of the opera- 
tion it is absolutely necessary that every portion of both ovaries 
should be removed. The smallest amount of ovarian tissue re- 
maining insures the continuation of the hemorrhage. When the 
fibroid is large, the entire removal is frequently attended with 
the greatest difficulty, as the adherent ovarian stroma can not 
be readily separated from the surface of the tumor. The opera- 
tion is still further complicated by the existence of tubal diseases, 
such as pyosalpinx, in which extensive adhesions bind together 
the ovaries, tubes, and tumor in one mass, so that castration will 
be attended with greater obstacles and danger than would be the 
removal of the uterus and ovaries. The operation should not be 
considered in cases of pure submucous myoma or in cystic de- 
generation of the fibroma. In pedunculated subserous and ad- 
herent tumors, and in very large interstitial growths, it is also 
contraindicated. In a freely movable uterus, in which the cervix 
can be readily reached, the operation affords no advantages over 
supravaginal amputation. Castration has a further disadvantage 
in not infrequently producing vasomotor symptoms, such as 
congestion, sweatings, hot flashes, pain in the head and sacrum. 
These symptoms are worse in the young than in those who are 
near the climacteric. Other symptoms are rather more rare, as 
obstinate vertigo, profuse leukorrhea, cardialgia, and occasionally 
vicarious bleeding. 

615. (8) Ligation of the Vessels. — The operation of castration 
having demonstrated the beneficial infiuence of ligation of the 



720 , GYNECOLOGY. 

ovarian arteries, it was a very natural step to proceed to ligation 
of these vessels through the abdominal incision in preference to 
the more radical operations of partial or complete hysterectomy. 
Hofmeier reported a case of Schroder's in which extirpation of 
the myoma seemed impossible, and where, in order to decrease 
the size of the tumor, the lateral and median vessels of the 
ovary were tied, with good result. Antal, at an earlier date, 
after ligation of the vessels observed an atrophy of the ovary, 
and, in place of castration, thereafter incidentally employed the 
mere ligation of the vessels in order to affect the function of the 
ovaries. Rydygier tied all six uterine arteries of a patient on 
the 27th of June, 1889. The spermatic arteries were ligated; 
then, after splitting the peritoneum near the cervix uteri, the 
uterine arteries were tied; and, finally, a ligature w^as placed 
about each round ligament. At the end of four months the 
tumor had decreased to three-fourths its former circumference; 
but after a year hemorrhage, which had completely ceased, re- 
appeared in a stronger degree, and the patient perished from 
marked anemia before radical operation could be performed. 
Byron Robinson has advocated the ligation of both ovarian 
arteries and the upper part of the uterine artery at the side of 
the uterus. This procedure is more effective in the smaller 
growths, and where hemorrhage is a marked symptom. 

616. (9) Myomectomy. — In more or less pedunculated sub- 
peritoneal fibroids there should be no question as to the ad- 
visability of myomectomy. The operation consists, when the 
pedicle is small, in cutting through it with scissors or knife and 
uniting the edges of the cut surface with sutures so deeply 
placed as to make sufficient pressure to control the bleeding. 
(Fig. 502.) When the pedicle is not large, its peritoneal covering 
should be cut through by the circular incision, turned down like 
a cuff, and the base of the pedicle ligated with chromic catgut 
and the tumor cut away, after which the peritoneal cuff can be 
united over the stump. In larger pedicles the operation consists 
in making peritoneal and muscle flaps, which can be brought 
together. In this way a single growth or a number of growths 
may be removed, leaving a normal uterus and the ovaries and 
tubes undisturbed. 

617. (10) Enucleation. — The ease with which smaller fibroid 
growths can be enucleated from their beds has led to the practice, 
by Martin and others, of shelling out interstitial fibroid growths 
from the uterine wall, leaving the uterus in place. (Fig. 503.) 
The procedure is performed as follows: The uterus is raised up, 
the position of the growths determined, and an incision made over 
the more prominent growth in a vertical direction in order to 
injure as few vessels as possible. The incision is made into the 



GENITAL TUMORS. 



721 



uterine wall and through the capsule, and the tumor is exposed. 
The tumor is then seized with a double tenaculum and drawn up, 




Fig. 502. — Abdominal Myomectomy 




Fig. 503. — Abdominal Enucleation of Myomata and Method of Closing the 

Uterine Wound. 



while with a blunt dissector the tissues are pushed off and the 
enucleation is accomplished. The removal of the tumor is fol- 
lowed by firmly packing a gauze pad into its cavity. If large 

46 



722 



GYNECOLOGY. 



vessels bleed, these should be seized and controlled with pressure 
forceps. The wall is still further investigated, and, when possi- 
ble, other fibroid growths situated within it should be brought 
through the first incision. This, in some cases, however, may 
involve more extensive mutilation of the uterus than would a 
separate incision over the mass. 

The advocates of this procedure generally limit it to the cases 
in which but a few growths are found in the uterine wall, and it 
was formerly particularly directed that the uterine cavity should 
not be opened. When we consider the investigations, however, 
of Menge and Kronig, which demonstrate that the uterine cavity 
is free from pathogenic germs, there should be no hesitancy in 
opening it, if necessary, to remove growths. In one patient I 
thus enucleated thirteen fibroids from the wall of the uterus, 
five of which were removed from the uterine cavity. After the 
operation the patient recovered without a single abnormal symp- 
tom. From another woman nine growths were removed. In 
another woman (unmarried) twenty growths were enucleated. 
What remained of the uterus was pretty well riddled, but it 
was sutured together and the patient completely recovered. 
In an unmarried woman nine growths were removed, five of 
them from the anterior wall. The loose tissue, being of low 
vitality, subsequently became necrotic, and in the sixth week 
after the operation this was withdrawn through a sinus in the 
abdominal wound ; convalescence subsequently was rapid. From 
an unmarried woman, a fibroid, which projected into the cavity 
of the uterus and had filled it up so that the tumor could be 
touched through the cervix, was enucleated through the ab- 
dominal cavity by posterior uterine incision. A gauze drain was 
passed through the cervix and the uterus closed over it. The 
patient recovered. 

After the enucleation of growths the wounds in the uterus 
should be carefully sutured by deep and superficial layers of 
chromic catgut, exercising the precaution to include and 
secure with the suture any large vessels in the wall which may 
bleed, and by the superficial suture to bring a good portion of 
the peritoneal surface of the uterus in apposition. Before the 
abdomen is closed all the wounds must be thoroughly inspected 
to see that hemorrhage is completely controlled. Should there be 
a tendency to excessive bleeding, it would be better to ligate 
the ovarian arteries as an additional safeguard. This operation 
is unsuitable for very large growths in which the uterus would be 
very extensively mutilated, or where the tumors are situated 
laterally and involve to a greater or less degree the Fallopian 
tube. In enucleation of intraligamentary growths the broad 
ligament is split, in order to expose the growth. In these cases 



GENITAL TUMORS. 723 

care must be exercised that the ureter has not been displaced 
upward by the tumor. It is important, also, to avoid injury to 
the ureter or its ligation in the subsequent closing of the broad 
ligament. 

6 1 8. (ii) Partial Hysterectomy, or Supravaginal Amputation 
of the Uterus. — This procedure was the earliest abdominal opera- 
tion performed for the removal of myomatous growths, and the 
earlier operations were cases of mistaken diagnosis, the pro- 
cedure having been undertaken for the removal of ovarian tumors. 
The first deliberate operation seems to have been performed by 
Burnham, of Lowell, in 1853, in which the patient recovered. 
A large proportion of the earlier operations were unsuccessful; 
the difficulty in controlling hemorrhage from the elastic stump 
rendered its intraperitoneal treatment exceedingly dangerous, so 
that the plan was practised of treating the stump extraperitoneally . 
The first to form a systematic method of operation was Koberle, 
of Strasburg. The method of performing the operation was as 
follows: The patient was placed in the dorsal position, and a 
long abdominal incision made in the median line, through which 
the uterus and tumors were delivered. The peritoneum above 
the bladder was incised and the latter stripped down, an elastic 
ligature or serre-noeud was placed about the cervix as low as 
possible, and pins were passed through it above the serre-noeud. 
The uterus and tumors were cut away sufficiently above the pins 
to prevent the traction of the stump from the grip of the instru- 
ment, the abdominal wound was closed down to the stump, 
while the latter was subjected to cauterization, and an applica- 
tion of persulphate of iron or tannin made to its raw surface 
to secure mummification. By some operators the parietal peri- 
toneum was fastened to the peritoneal covering of the stump by 
a continuous catgut suture. This procedure was done to promote 
the rapid union of the peritoneal surfaces and thus preclude the 
possibility of the discharges from the sloughing stump gravitating 
back into the peritoneal cavity. 

Occasionally, under this plan of treatment, the stump would 
become dry and gradually be thrown off without suppuration. 
It resulted, however, in an excavation, by the retraction of the 
stump, which had to close by a process of granulation, making 
convalescence prolonged. Often it was difficult to prevent 
putrefactive changes from taking place and resulting in suppura- 
tion. The weakened abdomen favored the subsequent develop- 
ment of ventral hernia. The difficulty in maintaining asepsis, 
the delayed convalescence, the weakened abdominal wall, led to 
the study of methods by which the stump could be treated within 
the peritoneal cavity. One of the earliest operators to attempt 
the intraperitoneal treatment was Schroder, who published in 



724 GYNECOLOGY. 

1880 an account of his cases. He opened the abdomen by a 
median incision, ligated that portion of the broad ligament con- 
taining the spermatic arteries with two ligatures, and cut between 
them. A similar course was pursued with the round ligaments. 
The stump, consisting of the cervax, was constricted by a rubber 
ligature, the mass cut away above the ligature, the stump caught 
with vulsellum forceps before the division w^as completed, and the 
cervical cavity cauterized with a 10 per cent, solution of carbolic 
acid. The divided surfaces were united near to the mucous 
membrane with sutures ; the raw surface quilted in with several 
rows of suture, and, finally, the peritoneum was sutured over the 
stump, after which the rubber ligature was removed. He em- 
ployed carbolized silk, and later juniper catgut, for sutures. 
Other operators have modified this procedure, as Zweifel, with 
partition ligature, and H. O. Marcy, with cobbler suture. Gow 
makes the following modifications : After delivery of the tumor 
through a median abdominal incision he ligates each round 
ligament on a level with the internal os, marks out an anterior 
peritoneal flap, and divides the round ligament and the anterior 
portion of the broad ligament between the uterus and the ligatures 
with scissors, carrying the incision toward the middle of the 
Fallopian tubes. The anterior flap is stripped down, the ovarian 
vessels and the Fallopian tubes enucleated and tied, so that at 
least one ovary is left. The broad ligaments are divided on the 
uterine side of the ligature, and bleeding from vessels connected 
with this portion may be temporarily controlled by clamps. He 
then marks out a posterior flap and dissects it downward for a 
short distance, seizes the uterine arteries with pressure forceps 
at the level of the os internum, cuts the tumor away with a knife, 
seizes and draws up the stump with vulsellum forceps, ties the 
uterine arteries, inserts a precautionary ligature by thrusting 
needles armed with silk through the stump from before backward, 
avoiding the peritoneum, so as to include the outer portion of the 
stump. This, done upon both sides, controls oozing or spurting 
from vessels which may have been given off obliquely. The 
bleeding area ma}^ also be encircled with a ligature passed by 
a needle. Two anteroposterior sutures are introduced through 
the muscular surface of the stump, avoiding the peritoneum; 
the raw surfaces, as a rule, are sewed together, the peritoneal 
flaps united, the peritoneum cleansed, and the abdomen closed.. 
Baer modifies this operation. His course is as follows : The patient 
is placed, in the Trendelenburg posture, and after separation of the 
adhesions the tumor and uterus are delivered through an abdom- 
inal incision, gauze is placed front and back, each broad hgament 
is transfixed by a single silk ligature, which, when tied, controls 
the ovarian arteries and veins. The ligated parts are then 



GENITAL TUMORS. 



725 



severed external to the tube and ovary,- incision being car- 
ried close to the cervix. The peritoneal reflection anterior to 
the uterus is cut through with scissors, the bladder stripped 
down with the handle of the scalpel, the uterine artery tied 
close to the cervix on each side and the cervix amputated just 
above the vaginal attachment. A small posterior fold is formed 
by stripping up the peritoneum while the amputation is made. 
The stump is now held in the grasp of tenaculum forceps. When 




Fig. 504. — Supravaginal Removal of Myomatous Uterus. 



the main arterial branches have been properly ligated, the raw 
end of the cervix will remain dry. (Fig. 504.) When all bleeding 
has been controlled, the peritoneal folds are loosely adjusted 
over the stump with Lembert sutures and the abdominal incision 
is closed. (Fig. 506.) The occasional accumulation of blood or 
serum beneath the peritoneum over the stump and its infection, 
forming a cellulitis or pus-collection, may delay convalescence. 
Le Bee, after abdominal section, draws out the uterus and 



726 



GYNECOLOGY. 



fibroids, ligates the broad ligament with a double ligature, and 
severs it between the ligatures. The round ligaments are 
ligated separately and the bladder with the peritoneal flap dis- 
sected down into the vagina. The tumor may be decreased 
in size by throwing a rubber ligature around the cervix and 
cutting away the mass above, or the tumor can be drawn over 
the pubes, a long curved forceps inserted into the vagina so 
that, when opened two or three centimeters, the posterior fornix 
is stretched. A small incision is made into the pouch of Douglas, 
and widened by opening the forceps. The tumor is drawn back 




Fig. 505. — Cervix Cut Across Preliminary to the Complete Ligation of One 

Ligament. 



and forceps are introduced so as to protrude against the anterior 
fornix, when the latter is treated in the same way. Care must be 
exercised, however, not to rotate the tumor to one side and thus 
injure the large uterine veins. One end of a long silk thread is 
seized by forceps, carried into the vagina, and brought up again 
through the opening in Douglas' pouch. Another thread is 
similarly applied on the opposite side. Both are tied, thus con- 
trolling the uterine arteries. The tumor is removed horizontally 
just above the ligatures, and only leaves a pedicle. This pedicle 



GENITAL TUMORS. 



727 



is split in the median line and as much cut away from each side as 
possible, only leaving sufficient to hold the ligatures. The long 
ends of these are seized with the forceps and drawn downward, 
the peritoneal flaps sutured together with catgut, and the abdo- 
men closed. The Pryor-Kelly modification of the operation con- 
sists in the ligation of the ovarian* vessel and round ligament 
and the division of the ligament upon one side. An anterior 
peritoneal flap is formed and the peritoneum and bladder stripped 
down. This exposes the uterine artery and veins, which|;are 
ligated by a ligature carried with a curved needle beneath them 
close to the side of the uterus, the organ is drawn to the opposite 
side, and the uterine vessels are divided. The uterus is cut 
across just above the vaginal junction. A pad of gauze is placed 




Stump Covered with Peritoneum. 



beneath the upper cut surface to prevent the intra-uterine dis- 
charges from escaping on to the wound while the canal below 
is wiped out. When near the opposite edge of the cervix, the 
incision is carried up one to two centimeters so as to leave a 
thin shell of cervical tissue and to expose the uterine vessels at 
a higher level, where they can be more easily .tied and with 
less risk of including the ureter. The uterine vessels are clamped 
and divided, the uterus is rolled still further over, the round 
ligament clamped and cut through. With still more traction the 
ovarian vessels come into view, when they are clamped and cut 
and the whole mass becomes free. All clamped vessels are then 
tied. Kelly ties all important vessels twice — once during the 
enucleation and again after it is completed. After control of ^ the 
hemorrhage, the stump is closed over the cervical canal by three 



728 GYNECOLOGY. 

to five catgut sutures. These sutures do not include the mucous 
membrane, the anterior peritoneal flap is drawn over the stump 
and united by continuous catgut suture to the posterior peri- 
toneum. Where a large space has been left in the cellular tissue, 
it is advisable to unite the peritoneum with interrupted or mat- 
tress sutures, so that blood can run into the peritoneum and be 
absorbed instead of forming a hematocele. Bishop modifies the 
operation by removing the cervix entire. When the broad liga- 
ment is ligated, having reached the stage of ligation of the 
uterine artery upon one side, instead of cutting across the cervix 
he has an assistant push up the lateral culdesac of the vagina 
and cuts down upon it, and thus enters the vagina. With the 
scissors the vaginal wall is then cut through entirely around the 
cervix, which is bodily lifted up with the rest of the uterus and 
rolled over toward the opposite side. The cervix is seized with 
strong forceps and pulled up against the free surface of the 
uterus. It has been previously plugged and, consequently, gives 
no trouble from the discharges. This procedure affords a ready 
method of enucleating intraligamentary fibroids, especially if 
they are situated upon one side of the abdomen. The entire 
removal of the uterus has another advantage, that there is no 
obstacle to drainage from the pelvis. He draws down into the 
wound a roll of iodoform gauze and closes the peritoneum over 
it. The abdomen is closed without drainage. E. C. Dudley 
claims that the union of the peritoneal flaps by transverse sutures 
permits the pelvic floor to sag down. Therefore he advocates the 
union of these surfaces by an anteroposterior line of suture. 
Where the cervix is left, a flap is made on each side. These 
are united, and over them the peritoneal flaps are drawn and 
secured by an anteroposterior line of sutures. The study of the 
evolution of any operative procedure would lead us to think that 
the originators of the plan studied to make it difficult. The 
constant aim of the operator should be to simplify procedures and 
secure the greatest expedition in the completion of the operation 
compatible with safety. With these purposes in view, after draw- 
ing out the uterus containing the growths, the most accessible 
broad ligament is clamped externally to the ovary and tube. 
One blade of the forceps being thrust through the ligament below 
the round ligament, and the tissue thus controlled, cut between 
the forceps and the uterus, the broad ligaments should now be 
spread out and the peritoneum divided anterior and posterior, 
the former flap can be easily made and the bladder pushed out of 
the way. The uterine artery is now readily seen and clamped, 
when the cervix can be cut across and, being dragged upon, ex- 
poses the uterine artery and later the ovarian, both of which 
should be clamped. Where the two sides of the pelvis are equally 



GENITAL TUMORS. 729 

accessible, the operator may prefer to proceed from above on each 
side. The vessels can now be secured, making sure that hemos- 
tasis is effective, after which the peritoneal flaps are united and the 
abdominal wall closed. An effort has been made in the fore- 
going pages to present to the student a resume of the various pro- 
cedures for the treatment of myomatous growths of the uterus. 
It is, however, recognized that when w^e come to treat the patient, 
he may be doubtful as to which method may be most applicable. 
I feel it but proper to indicate what I believe to be the preferable 
method of procedure. The operative procedure just described 
affords a ready method for dealing with those intraligamentary 
tumors which occupy only one side of the pelvis, but where we 
have the uterus filled up with fibroid growths and extending into 
the broad ligaments upon both sides and we can not reach Doug- 
las' pouch posteriorly, the problem for removal seems a most 
complicated one. The operation in such cases, however, can be 
very expeditiously performed by making a vertical section through 
the uterus and tumor from the fundus downward, dragging the 
masses to either side as the incision is made. The intestines, of 
course, are held back by gauze introduced behind the tumor, 
while the bladder is rendered visible as we proceed in the division. 
In this way the entire uterus may be split down to and through 
the cervix, or, if preferred, each side may be cut through at the 
vagino-uterine junction, leaving the cervix as a simple stump. 
As the lower portion is drawn upward, the uterine artery be- 
comes visible and is secured with clamp forceps. Further trac- 
tion upon the mass rolls out the fibroid growths from the broad 
ligaments, and later renders visible the ovarian artery, which is 
also secured. The broad ligament is clamped external to the 
ovary and tube, and the mass removed. A similar course upon 
the opposite side leaves us with the uterine and ovarian vessels 
clamped ready for the application of the ligature. 

The remaining steps of the operation may be completed as 
described in the previous operative procedures. 

619. (12) Panhysterectomy, or total extirpation of the uterus, 
is the procedure of election in those cases in which the cervix has 
been largely taken up by the extension of the growth, or when 
it has undergone extensive disease. This operation may be per- 
formed by a number of methods : 

I. The method of A. Martin, of Berlin: With the patient in 
the dorsal position, through a large median incision the tumor 
is drawn out, and, if necessary, can be made more movable by 
the enucleation of masses after the capsule has been split. The 
infundibulopelvic ligament is ligated and the broad ligament 
divided until the cervix is reached, beginning usually upon the 
left side, but in all cases on that in which the procedure would 



730 ~ GYNECOLOGY. 

be most complicated. Having completed ligating one side before 
attacking the other, a pair of clamp forceps is applied on the 
uterine side of the line of ligature. The broad ligament is then 
divided betAveen the forceps and ligatures to the ceryix. The 
uterus can then be brought over the symphysis pubis, the pos- 
terior fornix is cut through by scissors, close to the cervix, and 
the two edges of the wound united by sutures. Sometimes bent 
forceps are passed, and from the vagina made to tear through 
the posterior fornix into Douglas' pouch, and, by separating the 
blades, the structures are torn with less danger of bleeding. A 
ligature is passed around the lower attachment of the broad 
ligament on the one side, which is then divided. The os is 
seized with a pair of forceps, which both closes the cervical canal 
and draws the cervix upward and backward into the peritoneal 
cavity. The other side of the broad ligament can now be secured 
in a similar manner. The anterior vaginal fornix is then divided, 
and the firmer bands of connective tissue one will meet in this 
situation. When these are cut through, the cervix separates 
easily from the bladder. Bleeding vessels are secured with the 
ends of the ligatures drawn down into the vagina. The periton- 
eum is united by transverse sutures over the vaginal wound, and 
the abdominal wound closed without drainage. 

II. The method of Christopher Martin, of Birmingham: With 
the patient in the dorsal position, he delivers the tumor through 
a median incision and packs gauze pads above and below. A 
double thread is passed through the broad ligament at the 
junction of its upper and middle thirds, and midway between 
the uterus and pelvic wall. These two sutures do not interlock. 
By pulling them forcibly inward and outward, the punctured 
aperture is torn with a transverse slit and the two ligatures are 
tied as far apart as possible and the intervening broad ligament 
divided. The same process is repeated on the opposite side. 
He prefers, where possible, to leave one ovary and tube. The 
other is removed with the uterus. A second ligature is passed 
through the broad ligament about the level of the internal os 
and nearer to the uterus than the first one. The aperture punc- 
ture is again stretched, when the ligature is tied as far apart 
as possible and the intervening tissue divided. The bladder is 
then separated from the anterior surface. He also advises the 
use of the sound in the bladder, to define its upper edge. A 
curved incision, two-thirds of an inch from the upper edge of 
the bladder, is made from one broad ligament to the other, 
and the bladder is stripped down. The surgeon can determine 
when he has reached the vagina by following the tip of a pair 
of forceps pressed into the anterior fornix. The vagina is opened 
upon these with scissors and the opening enlarged. The posterior 



I 



GENITAL TUMORS. 



731 



fornix is similarly treated. The ureters, when seen, are pressed 
outward. The uterine arteries now remain to be tied. Ligatures 
are passed through the remaining portion of the broad ligament, 
hugging close to the mucous membrane of the lateral fornix of 
the vagina, and 'are tied upon either side. The uterus is then 
cut loose, keeping the scissors as far as possible from the two 
lower sutures. The cut edges of the vaginal walls are drawn 
upward with forceps and carefully inspected. All blood-clots are 




Fig. 507. — Panhysterectomy. Doyen's method. The tumor rolled out, inci- 
sion made from Douglas' pouch into the vagina upon the end of a pair 
of forceps. 



sponged out of the pelvis and all bleeding points ligated. The 
ligatures may be cut short or may be left long and the ends em- 
ployed to draw^ the stumps into the vagina. The vaginal wound 
is not closed, but is filled with a thick roll of iodoform gauze 
drawn through into the vagina. The abdomen is closed by inter- 
rupted silkworm-gut sutures. The gauze placed in the vagina 
is removed on the fifth or sixth day. 



732 



GYNECOLOGY. 



III. Doyen's method: With the patient in the Trendelenburg 
posture, the tumor is lifted out through an abdominal incision 
and drawn forward over the pubes. A long, curved forceps, 
previously passed into the vagina, is made to project into Doug- 
las' pouch, upon which an opening is made into the vaginal 
canal. (Fig. 507.) Through this opening the cervix is seized by 
the anterior lip, if possible, and drawn upward and backward. 
While held in this position, the entire circumference of the attach- 
ment of the vagina to the cervix is under view and can be divided 
by scissors. (Fig. 508.) The cervix is separated from the blad- 




Fig. 508. — Cervix Separated from the Vagina and Being Pulled Away from 
the Bladder and Ureters. 



der by traction upward until the peritoneum above the bladder is 
reached, which is broken through and pushed back. The broad 
ligament external to the ovary and tube on the right side is 
clamped and incised with scissors. Clamp forceps are then applied 
to the broad ligament of the opposite side, when it likewise is cut 
through external to the ovary and tube. Frequently, by this 
method of procedure, the uterine arteries are not injured. The di- 
vision is so close to the cervix that the main branch is not divided, 
and it is only the smaller branches that are torn, and consequently 
do not bleed. The pedicles of the broad ligaments are ligated. 
The uterine arteries are also ligated and forceps removed. The 



GENITAL TUMORS. 733 

vaginal mucous membrane can be united by two or three sutures 
with the peritoneum to prevent subsequent prolapse. The ends 
of the ligatures on the arteries are turned down into the vagina, 
and the pelvic peritoneum can be tinited by a purse-string suture 
across the pelvis, ,so as to invert the stump of the broad ligament 
below this structure. The abdominal wound is closed without 
drainage. Doyen, in his earlier operations, trusted to the angio- 
tribe alone, but later applied a catgut ligature in the groove. The 
latter procedure is preferable. 

IV.. Schauta's method: The tumor and uterus are drawn out 
through a median incision and the broad ligament on each side 
divided between clamp forceps. The anterior peritoneum is 
divided and, with the bladder, stripped down to the vagina; 
the tissues are clamped upon each side and the vagina opened 
right and left between the clamps and the uterus. The tumor 
is now held by the anterior and posterior vaginal walls, which 
are secured by curved clamps, and the uterus removed. Liga- 
tures are substituted for the clamps, which are left long and 
employed for vaginal drainage. The abdominal cavity is closed 
by union of the peritoneal folds over the vagina. 

V. Richelot, through an abdominal incision, first separates 
the anterior peritoneal fold and bladder. The uterine arteries 
are found, clamped by forceps, and cut close to the uterus. 
The anterior culdesac is found and opened ; the cervix seized and 
drawn upward and for^vard. The cervix is separated from the 
vagina by a circular incision, and the broad ligaments are separated 
in sections from below upward. This plan affords an effective 
procedure when there are extensive adhesions following disease 
of the appendages. All the clamped vessels are securety ligated 
and the vaginal wound is closed with catgut. 

In difficult cases Bishop employs what he calls the combined 
method, which may be begun either from below or from above. 
In the former the patient is placed in the lithotomy position, 
the uterus exposed by retractors, seized, and drawn down with 
vulsellum forceps. The cervix is cleansed, packed with gauze, 
and if there is much discharge, the os is closed by a suture. 
A circular or ovoid incision is then carried around the cervix, 
completely dividing the vagina, when, with the finger hooked 
closely to the uterus, the bladder is separated from the anterior 
surface of the uterus and well to either side. In large tumors 
this can not be accomplished to a great extent, but should be 
sufficiently to expose the uterine vessels. Douglas' pouch is 
opened, and, with the one finger behind and the thumb in front, 
the uterine artery should be defined, ligated, and the ligament 
cut as far as the ligation extends. Hemorrhage is carefully con- 
trolled and the vagina loosely packed with gauze. The patient 



734, GYNECOLOGY. 

is then changed to the Trendelenburg posture and the abdomen 
opened through the rectus sheath of one side. All adhesions to 
omentum and intestine are separated, and, where indicated, 
ligatures applied. A gauze pad is placed over the intestine. 
When the ovaries and tubes are healthy, they are to be left. 
When diseased, part of the ovary at least is retained. One 
ligature is made to embrace the ovarian ligament, if the tube 
and the round ligament near the appendages are healthy enough 
to permit of their being retained, and is tied as near to the 
uterus as the retention of the ligature will permit. The ligament 
is cut close to the side of the uterus. The lateral incisions are 
joined by a curved incision anterior to the uterus, about half 
an inch above the line of the bladder, which is stripped down 
until the previous separation has been reached. The uterus is 
now attached only by the central portion of the broad ligament 
upon each side, which is ligated and the uterus cut away. Bleed- 
ing vessels are ligated and the ligatures cut short, the pelvis 
dried, a roll of gauze pulled through into the vagina, and the 
peritoneal flaps closed over it with a continuous catgut suture. 
All raw edges are carefully inverted into the vagina, so that the 
peritoneal wound is perfectly smooth. Bishop closes the ab- 
dominal wound with catgut for the peritoneum, crin de Florence 
for the aponeurosis, and horsehair for the skin. With the inser- 
tion of the last layer, the skin should be cleansed, dried, and 
painted with celluloidin, which forms an air-tight covering. 

Bouilly preferred to begin from above and finish from below. 
He delivers the tumor through the median abdominal incision 
with the patient in the Trendelenburg posture, divides the 
broad ligament between double ligatures, incises the peritoneum 
in front of the uterus, and pushes down the flap with the bladder, 
ligates the broad ligament so as to include the uterine arteries, 
amputates through the cervix, and closes the abdomen. Then, 
with the patient in the lithotomy position, he removes the 
cervix per vaginam, sutures the peritoneal flaps from below, 
and plugs the vagina with gauze. This procedure is particularly 
valuable in a sloughing fibroid which communicates with the 
vagina. 

620. Summary. — Notwithstanding the recent able contribu- 
tions to the literature of this subject, in which the writers advocate 
radical measures, in the great majority of the victims I remain con- 
vinced that the aim of the surgeon should be to save and not 
sacrifice. A hysterectomy, partial or complete, should be his 
practice only when it is impossible to preserve a functionating 
uterus. In submucous growths, with hemorrhage as a marked 
factor, the tumor, when accessible, should be removed by torsion 
or excision of its pedicle. When the tumor is still within the cavity 



GENITAL TUMORS. 735 

of the uterus, the cervix may be dilated with laminaria tents, and 
if sufficient room is not thus secured, the os can be spht by a lateral 
or an anterior incision, as may be most convenient, and the tumor 
removed by torsion, by excision of its pedicle, or by enucleation. 
If the tumor is tx)0 large to permit of its ready extirpation, it 
should be removed by morcellation. Vaginal hysterectomy should 
be confined to uteri containing growths which are not too large to 
permit of their ready passage through the vagina, and yet in which 
the uterine structure is so taken up .and involved as to preclude 
the retention of a healthy organ, or in which the ovaries and tubes 
are secondarily involved, making the retention of the uterus 
after the removal of the gro^^^hs of no value. Of the various ab- 
dominal operations, myomectomy, enucleation of the growth, or 
partial or complete hysterectomy can be performed. Of the 
abdominal operations named, the principle already enunciated, 
that no organ should be sacrificed the function of which can be 
maintained, must govern as well in the abdominal as in the vaginal 
procedures, and when the ovaries and tubes are in a condition to 
justify the retention of the uterus, myomectomy or enucleation 
should be practised, even though a number of growths are present. 
The objection to enucleation frequently advanced, that the cic- 
atricial changes in the uterine w^all w^hich will result from the 
enucleation of a number of growths will unfit the organ for the 
exigencies of gestation, labor, and the puerperium, would seem 
to be valid and can be combated only in the line of experience. 
To contribute to this service I would relate the history of the 
following patient: Miss L., a Japanese woman aged thirty- 
three years, a patient of Dr. A. B. Shimer, of Atlantic City, was 
sent to me in February, 1903, because of an abdominal tumor. 
An irregular nodular mass was found in the median portion of 
the abdomen, projecting two inches above the symphysis and a 
little to the left. Careful physical examination made it mianifest 
that it was a part of the uterus and that it filled up the pelvis. 
Hysterectomy was advised. She entered St. Joseph's Hospital 
the latter part of April, 1903, when the growths were exposed by 
abdominal incision. They were found so situated in the anterior 
and posterior walls of the uterus that enucleation seemed pos- 
sible. The gro\^1:hs, thirteen in number, were enucleated, but 
without opening into the uterine cavity. The anterior wall of 
the uterus Avas much mutilated, but was quilted together, pro- 
ducing a very satisfactory appearing organ. To prevent the 
uterus from falling back into the pelvis the fundus was secured 
to the abdominal wall by two turns of the continuous catgut 
suture closing the parietal peritoneum. She developed an in- 
fection of the abdominal wound from which considerable pus 
was discharged. Four weeks following the operation a slough 



736 GYNECOLOGY. 

was removed from the depths of the wound, which contained the 
catgut sutures employed to close the uterine wound, after which 
the recovery was rapid and the patient was discharged cured. 
A communication from Dr. Shimer, dated June i6, 1906, in- 
forms me she was married on the 14th of October, 1903, and in 
November, 1904, gave birth to a healthy child weighing seven and 
one-half pounds. As the presentation was a vertex in an occipito- 
posterior position, the delivery was instrumental. Subsequent to 
her delivery her health has been excellent. The history demon- 
strates that excessive cicatricial change in the uterus does not render 
such a patient unable to meet the exactions of pregnancy. A 
number of instances have been reported where examination has re- 
vealed unsuspected malignant degeneration complicating the 
tumor ; also reports of recurrence in the stump, the danger of which 
is lessened by panhysterectomy. Another disputed question is 
whether the ovaries shall be removed or one or both be retained. 
Those who advise the retention of an ovary claim that its pres- 
ervation prevents the distressing symptoms associated with the 
premature menopause. I formerly practised the retention of 
ovarian stroma whenever possible, but such unused organs early 
atrophy, and the distressing phenomena become just as acute. Not 
infrequently will it be found necessarv^ to reoperate because of neo- 
plastic changes in the ovary. In many cases the changes in the 
tube and ovary already exist, making the removal of these organs 
desirable. When the uterine structure is greatly involved or when 
ovarian, uterine, or tubal disease complicates the condition, the 
operator may be forced to resort to either partial or complete 
hysterectomy. My experience inclines me to advise complete 
hysterectomy, for the retention of the cervix affords no special 
advantage. Its complete removal does not add to the difficulty 
nor prolong the operation. It affords better drainage and ex- 
pedites the recovery of the patient. In nearly all cases the clean 
removal of the uterus, ovaries, and tubes is more readily ac- 
complished than is the retention of an ovary. No one operation 
can be made applicable to every patient. In the majority the 
Doyen operation will prove the most satisfactory. When the 
broad ligaments are shortened by inflammation and the pelvis 
filled up by myomata, the operator may be unable to reach the 
cervix. Then, of course, another method of procedure must be 
chosen. The uterus containing the growths may be divided by 
vertical section, and through the culdesac portions of the tumor 
mass can be enucleated, thus decreasing the size of the structure 
and affording more room. Proceeding from below upward in- 
traligamentary growths are shelled out with but little danger to 
the ureters, and better facility is afforded to secure hemostasis. 
Where access to one side of the pelvis is partially barred by in- 



GENITAL TUMORS. 737 

flammatory shortening or the ligament is occupied by myomata, 
the Bishop modification of the Pry or- Kelly operation permits 
ready removal of the uterus and growths. 

621. Accidents during Operation. — Hemorrhage is an accident 
which is avoidable with careful application of ligatures. Where 
the tissues are ligated en masse, the angiotribe, by the com- 
pression of the tissue, forms a groove in which the ligature may lie 
with less danger of its loosening. Where the ligated mass is large 
and vessels are greatly distended, it is prudent to place a second 
ligature back of the first upon the more important vessels. The 
compression furnishes a button over which the ligature is unlikely 
to shp. When the cervix is retained, bleeding from the stump is 
avoided by applying ligatures upon each side to control the blood- 
supply from the uterine arteries. One advantage of the entire 
removal of the uterus is that hemorrhage, when it occurs, is at 
once revealed by its discharge from the vagina. Internal hemor- 
rhage will be indicated by symptoms of increasing shock, and the 
occurrence of such symptoms should be considered an indication 
for prompt reopening of the wound to secure the open vessel, 
for, should the patient rally from the hemorrhage, the large 
accumulation in contact with the intestine in the weak state of 
the patient adds to her subsequent danger from the possibility 
of sepsis. All bleeding vessels should be firmly secured before 
the peritoneal wound is closed. Care must be exercised in short 
broad ligaments that the ovarian artery is not retracted behind 
the peritoneum from the grasp of the Hgature, there to produce a 
concealed hemorrhage or thrombus which may become so large 
as to open into the peritoneal cavity. 

Injuries to the Hollow Viscera. — In the injuries to the viscera 
the bladder is most likely to be affected, as it is often drawn up 
by the growth and is closely attached to its anterior surface. 
Its relations to the uterus and tumor will largely depend upon the 
situation of the growth. A tumor which has originated in the 
lower part of the anterior wall of the uterus may very readily drag 
up the bladder and cause it to be displaced upward. The bladder 
may be displaced to one side, and not cover the anterior surface 
of the uterus and tumor. This may readily occur because of 
partial torsion of the neck of the uterus or from the size of the 
growth. In one case I accidentally incised the bladder when 
opening the abdomen, as it was displaced upward and to the left 
side and formed a quite distinct tumor that did not entirely dis- 
appear after the employment of the catheter. The opening was 
immediately sutured, the bladder separated from the surface of 
the growth, and the recovery of the patient was unretarded. 
Inflammatory adhesions may bind the bladder to the anterior 
surface of the tumor, and in the subsequent development may 
47 



738 GYNECOLOGY. 

drag it so high that it is overlooked in the separation of adhesions. 
In such a way I was so unfortunate as to incise the fundus where 
adhesions were extensive, invoh'ing both anterior and posterior 
surfaces. In this patient recovery took place after the bladder 
wound was sutured. When the bladder is injured, the wound 
should be closed by sutures at once, whether it occurs upon the 
peritoneal or on the nonperitoneal surface. Precaution should 
be excised in the use of the sutures that they do not enter the 
vesical mucous surface. It is well to have a double row of sutures, 
in order to bring a larger surface of bladder-wall in apposition, 
and in the subsequent convalescence the bladder should be 
frequently evacuated. When the wound has been extensive, 
it would be advisable to employ a permanent catheter for the 
first week, and for the second week to have the urine drawn 
at frequent intervals. The possibility of displacement of the 
bladder by the gro^^1:h should always be considered, and care 
should be exercised to avoid its injury. 

Injuries of the Ureter. — The situation of the ureter alongside 
the cervix makes it particularly vulnerable in the removal of 
large fibroid growths and especially where the growth has de- 
veloped low in the broad ligament. In some cases the growth 
shoves the ureter upward until we find it in a groove between 
the tumor and the uterus. In such patients the dissection should 
be most carefully practised in order to avoid injury to the ureter. 
The Doyen operation lessens the danger to both bladder and 
ureter ; the cervix is pulled away alike from the bladder and the 
ureters. In the intraligamentary variety the tumor is dragged 
away from its relations to the ureter. In cases of injury, and 
particularly where the ureter has been cut, the proper course 
would be to establish: (i) An anastomosis between the ends of 
the divided ureter. (Fig. 234.) The union can be end to end, the 
cut surfaces being made oblique. Another method is to split 
the vesical end and scrape the mucous surface and insert the renal 
end , securing it b}^ sutures ; ( 2 ) the transplantation of the renal end 
into the bladder. (Fig. 233.) In introducing the ureter, it is im- 
portant that it should be anchored in the bladder in such a way 
as to prevent it slipping back or drawing away from its attach- 
ment to the bladder surface, which would permit the urine to es- 
cape into the peritoneal cavity. If the union with the bladder is 
difficult, because the injury of the ureter is situated so high. that 
the latter reaches the bladder only upon slight stretching, it is 
better to anchor the bladder to the side of the pelvis at a higher 
level, so that no traction shall be made upon the shortened 
ureter. When the ureter is too short to permit of an anastomosis 
with its vesical end or its transplantation into the bladder, the 
following alternative procedures have been suggested: (3) carry 



GENITAL TUMORS. 739 

the ureter across and anastomose it with the ureter on the oppo- 
site side. This procedure in my judgment is only to be mentioned 
in order to be condemned. If long enough to permit of this, it 
should be introduced into the bladder. I should hesitate about 
imperiling the patient by disturbing the remaining conduit. 

(4) The introduction of the ureter into the correspond- 
ing colon. This operation has not been attended with very 
satisfactory results. The infection and gases from the intestine 
have been known to be carried through the ureter to the pelvis 
of the kidney, producing fatal inflammation. The contact of the 
tirine with the intestine will cause considerable irritation and 
produce a marked diarrhea. 

(5) Bring the extremity of the ureter out through the ab- 
dominal wound or make a fistulous opening upon the skin sur- 
face. Such a procedure is attended with no little discomfort 
to the patient, as the constant soiling of the person and cloth- 
ing with the urine is very distressing to a cleanly patient and 
annoying to those who have to be associated with her. 

(6) Ligate the ureter and drop it back. This ligation should 
be made by a double ligature, for the reason that, under 
the process of pressure-atrophy, the ligature becomes loosened 
and, when single ligatures are used, the urine escapes into the 
peritoneal cavity and causes urinary infiltration and septic 
peritonitis. This condition is less likely to occur when a second 
ligature is applied from half an inch to an inch above the first. 
The urine continues to be secreted until the pressure within 
the cavity of the kidney is equal to the blood pressure, when 
the secretion is arrested. In such cases the kidney, unable 
longer to secrete the urine, becomes a useless organ and atrophies, 
while the extra work is taken up by the remaining kidney. 
The result of the procedure, of course, will depend, as it would 
in nephrectomy, upon the condition of the other kidney. 

(7) Removal of the kidney. 

Intestinal Injuries. — Injuries of the intestine are less fre- 
quent. They may occur as a result of extension and firm ad- 
hesions to the surface of the growth. The injury is much more 
likely to take place in the sigmoid flexure of the descending 
colon and the rectum. As a result of chronic inflammation, 
the adhesions may be very extensive and firm, and lead to the 
injury of the intestine before its possibility could be suspected. 
In all cases of extensive adhesions, after the removal of the 
growth careful examination should be made to ascertain the 
existence of intestinal injury. Such adhesions may also result 
from complications incident to suppurative disease of the tubes 
associated with the gro\\^h. Very frequently an opening will 
occur between a tubal abscess and a knuckle of intestine through 



740 GYNECOLOGY. 

which the contents of the abscess have been partially drained. 
During an operation for the removal of a fibroid growth associated 
with pelvic suppuration I found an opening from the left tubo- 
ovarian sac into the anterior surface of the sigmoid, through which 
the thumb could be introduced. This sinus had served to empty 
the abscess at frequent intervals. In closing an intestinal open- 
ing its edges should be careftdly trimmed and thus remove tissue 
of low vitality or such as has been injured during the procedure, 
and secure contact of the surfaces by a double row of sutures. 
Continuous chromic catgut suture is a very serviceable material, 
but, as has been previously mentioned, the suture should be so in- 
troduced as to hold extensive surfaces in apposition. The patient 
should subsequently be kept upon an albuminous broth diet, and 
early evacuation of the bowels should be accomplished, afford- 
ing no opportunity for hard fecal masses to form in this portion 
of the intestine. In these inflammatory fistulous cases gauze 
packing drainage is generally advisable, for it is always difficult 
to make certain that all tissue of low vitality has been excised 
and that a fistulous opening may not recur. When the abdominal 
wound is closed, leakage may cause fatal infection of the peritoneal 
cavity before the gravity of the condition is recognized. If a 
small fistulous opening follows in such a patient , it is preferable 
to keep the wound open and the cavity thoroughly cleansed by 
frequent irrigation both by the rectum and the abdominal wound, 
and to permit nature an opportunity to close the opening by 
granulation. Nature soon shuts oft' the tract of the general 
peritoneum and prevents the possibility of its infection. To 
reopen such a wound in order to close the fistula increases the 
danger of general infection. Where the caliber of the intestine 
is free and unobstructed, a fistula will close by granulation, but 
should the intestine be obstructed or kinked below the fistula, 
the latter will not close. The efiect of a fistula will depend upon 
its size and position in the intestinal tract. Free discharge from 
the intestine high up means that much nutritive fiuid is removed 
from the processes of absorption. Therefore a corresponding 
loss of vitality results. A fistula in the large bowel, however, 
may exert but little influence upon the general nutrition. 

622. Causes of Death Following Hysterectomy. — The most 
frequent causes of fatal results are: shock, hemorrhage, and 
septicemia. Shock is a vasomotor disturbance which may result 
from severe hemorrhage during or previous to the operation. It 
is especially prone to occur in individuals in whom the percentage 
of hemoglobin is small. It is promoted by prolonged operations, 
injudicious administration of anesthetic, exposure of the viscera 
to cold, or drying in the atmosphere. It is more likely to occur 
in the neurasthenic and poorly nourished, in victims of tuber- 



GENITAL TUMORS. 741 

culosis, or in patients who have been suffering from prolonged 
inflammatory complications. In fibroid gro^^i:hs complicated 
by dense inflammatory adhesions the traction upon important 
sympathetic ganglia in breaking up adhesions may be attended 
by fatal shock. 'Hemorrhage may be the cause of death during 
or shortly following an operation, from rupture of a large artery 
or vein, or from failure to control bleeding during the procedure. 
These occurrences should be rare, as the operator and his assistant 
should be alert to secure vessels before they are injured or upon 
the first spurt when the vessel is severed or torn. A fatal hemor- 
rhage may result from the retraction of an important vessel or 
from the slipping and loosening of an insecurely placed or tied 
ligature. This is more likely to occur when the pedicle is short 
and thick and is tied en masse. Unless the gravity of the con- 
dition is appreciated at once, the hemorrhage may be rapidly 
fatal. If the enfeebled condition of the patient leads to the for- 
mation of a clot and arrest of bleeding, the large accumulation of 
blood in the peritoneal cavity may still be a source of danger to 
the patient through its infection by its contact with the intestine 
or from pathogenic germs which may have been left in the ab- 
dominal cavity. In this sense it may furnish the cause for the 
subsequent death of the patient from septicemia. The danger 
from septicemia is greatly enhanced where the operation has been 
difficult, due to intraligamentary growths; when the operation 
has been complicated by extensive adhesions, suppurative proc- 
esses in the tubes, and hematoma of the ovaries. Less frequent 
but none the less to be regarded causes are pneumonia, pulmonary 
embolism, ileus, tetanus, and secondary manifestations of sepsis, 
as phlebitis. (For after-treatment see Post-operative Treatment, 
Sections 206-220.) 

623. Puerperal Tumors. — Physometra. — An unusual form of 
enlargement of the uterus, giving the appearance of a tumor, 
results from the condition just named, which is an accumulation 
of gas in the interior of the uterine cavity. This aft'ection 
may be produced during the puerperium or without it. After 
the woman is delivered the uterus is large and air will enter it. 
If expulsion is delayed by ineffective contraction of the organ, in 
the course of the convalescence the placental fragments or re- 
tained portions of membrane undergo decomposition and pro- 
duce a putrid gas, which, by larger accumulations in the organ, 
produces the condition known as physometra. It may develop 
in the nonpuerperal uterus, as is well indicated in the following 
patient, as cited by Auvard: A negress, forty-six years of age, 
reached the menopause and presented considerable abdominal 
enlargement. Her periods had not been seen for three months. 
According to her calculation, she was certainly pregnant. The 



742 GYNECOLOGY. 

term had passed four months; she called a physician and ar- 
ranged that he should attend her in labor. Under an attentive 
examination of the patient to determine the cause of the uterine 
enlargement a hysterotome was introduced into the cavity of 
the uterus, when, in less than a minute's time, with great 
impetuosity, an offensive gas was driven out. After this evac- 
uation the uterus returned to its normal proportions and the 
patient recovered. In the acceptance of this condition we 
must admit the possibility of the secretion of gas in the uterine 
cavity, or the putrefaction of retained intra-uterine debris 
after the occlusion of the cervical canal. Decomposition of 
the debris results in the formation of gas and the distention of 
the organ. The treatment consists in the establishment of 
the permeability of the canal. 

624. Hydrometra is due to any cause by which the internal 
orifice of the uterus becomes closed and the secretion retained 
in a woman who suffers from amenorrhea or in one suffering 
from endometritis after the climacteric has occurred. It prac- 
tically produces a mucometra, or, when the liquid is serous and 
clear, it is denominated hydrometra — a term which includes 
all seromucous uterine collections. If the endometritis is pur- 
ulent, w*e have a pyometra. Hydrometra is exceedingly 
rare. 

625. Hematometra is an accumulation of blood in the in- 
terior of the uterus, and has been described under malforma- 
tions. 

626. Pyometra. — Pyometra is an accumulation of pus in the 
uterus, and is more likely to be found in women some years after 
the climacteric. 

627. Hydatid Cysts of the Uterus. — The condition called 
hydatid cysts of the uterus is, however, free from the presence 
of hydatids. There are a large number of cysts, which form 
in the mucous membrane of the uterine cavity — a condition 
which generally follows labor or abortion, and is known as cystic 
mole. It is so closely associated with the condition known as 
deciduoma malignum that its consideration will be postponed 
until the discussion of the latter disease. 

628. Mucous Polypi of the Uterus. — These are growths which 
arise from the uterine mucous membrane, and are distinct from 
the fibroid polypi, with which they are often confounded. (Fig. 
509.) The latter arise from the muscular wall and push before 
them the mucous membrane. The former result from hyper- 
trophy of the glandular structure of a limited portion of the uterus, 
which causes them to push out and form a polypoid growth. A 
number of these may occur within the cavity of the uterus and 
interfere with the performance of its functions. They are associ- 



GENITAL TUMORS. 



743 



ated with endometritis. They are due to a locaHzed inflammation 
and hypertrophy of the glandular tissue. These growths may 
vary from the size of a filbert or less to a growth consisting of a 
grape-like cluster of glands attaining the size of a small orange, 
which is extruded from the cervix and hangs by a pedicle from 
the uterine cavity. These growths may occur upon any part of 
the mucous membrane; frequently they arise from the cervix 
and protrude from the os in small masses. The treatment of 
these growths is the same 
as that of the inflamma- 
tion with which they are 
associated: thorough 
curetment of the uterus ; 
removal of the growths; 
disinfection and steriliza- 
tion of the uterine canal, 
and gauze packing to pro- 
mote subsequent drain- 
age. The operation 
should not be devoted 
to the removal of the 
growths alone, as the 
cervical canal is likely 
to become irritated and 
cause subsequent pelvic 
inflammation. 

Another form of uter- 
ine tumor is placental 
polypus, which consists 
of a mass of coagulated 
blood, in association with 
a portion of the placenta 
or the decidua, which 
hangs by a pedicle from 
the uterine cavity and 
acts as a source of irrita- 
tion until its removal. 
The mass becomes com- 
pressed in the uterine cavity and forms a firm growth, which 
can subsequently become partly organized, or, under the influ- 
ence of insuflicient nutrition, may become decomposed, and cause 
putrid intoxication. The treatment will consist in the thorough 
removal of the growth. This can be done with the flnger or by 
the introduction of forceps, which seize and twist off the tumor. 

'629. Malignant Tumors. — Malignant neoplasms, as seen by 
our classification, originate in embryonic tissue and are divided, 




Fig. 509. — Mucous Polypi. 



744 GYNECOLOGY. 

according to their origin, into two classes : the epitheHal and the 
connective tissue. They differ from the benign in having no 
limit to their growth and extension. A malignant tumor is one 
which destroys the organ in which it originates and penetrates 
to the surrounding structures without limit to its gro\\1:h. There 
is no tissue of the body which can offer effective resistance to its 
encroachment. Malignant growths are further characterized by 
a tendency to extend themselves to remote tissues and organs by 
transmission through the lymph- and blood-vessels. Loosened 
pieces of tissue or infectious products are washed away from 
their original source to new locations, thus affording development 
to new foci of the structure similar to that from which they 
originated. A further characteristic is that they exhibit a dis- 
position to recur after removal. The limit between malignant 
and benign tumors is difficult to fix. Thus, papillary ovarian 
cysts may rupture and subsequently implant themselves upon 
and infect the general peritoneal cavity. Syphilis and tuber- 
culosis manifest an inclination to extend to the surrounding 
structures and to be reimplanted through the blood-vessels. But 
the manifestations of syphilis and tuberculosis are capable of 
modification, of arrest, and even cure. The papillary infection 
generally undergoes atrophy and disappears when the original 
source of infection has been removed. 

630. Classification. — Pathologic classification of malignant 
disease of the uterus can be arranged as in other organs of the 
genital tract, in tumors springing from the embryonal epithelial 
cells, of w^hich there are tw^o v^arieties, namely: carcinomata and 
chorio-epithelioma, and from the embryonal connective-tissue 
tumors, of w^hich there are also two varieties of malignant dis- 
ease, namely: sarcoma and endothelioma. The carcinomata 
may develop from any portion of the uterine mucous membrane 
from the cervix to the fundus, and in either the surface epithe- 
lium or that lining the glands. Chorio-epithelioma develops in 
the second layer of cells, known as Langhans' cells, covering the 
chorionic villi. Sarcomata may originate in the connective tissue 
of the endometrium or in the tissue of the mural portion of the 
organ. Endotheliomata develop from the endothelial cells of 
the lymph-vessels, blood-vessels, and the serous covering of the 
uterus. Furthermore, they are, as a rule, without any alveolar 
arrangement. 

631. Anatomic Classfication of Carcinoma. — Carcinoma may 
arise from any portion of the mucous membrane lining the 
uterus or that coA^ering the cervix external to the os, the latter 
being the portion denominated by the Germans as the portio 
vaginalis. According to the anatomical location, carcinoma is 
classified into : i , Carcinoma of the vaginal portion of the cervix, 



GENITAL TUMORS. 745 

that portion between the external os and the vaginal vault; 2, 
carcinoma of the cervical canal, which is bounded below by the 
external os and above by the internal; and, 3, carcinoma of the 
corporeal mucous membrane, whose inferior boundary is the 
internal os. Carcinomata are further classified histologically 
into squamous-cell carcinoma and the cylindric-cell carcinoma 
or adenocarcinoma. Squamous-cell carcinoma is the form of 
disease found in the epithelial covering of the vaginal portion of 
the cervix. In rare instances it has been described as having 
originated in the endometrium of the uterine body, and its origin 
there can be explained only by the presence of parasitic epithelial 
cells. According to Cullen, but three authentic cases have been 
recorded in literature. Cylindric-cell cancer develops from the 
epithelial covering of the mucous membrane and from the epithe- 
lial cells lining the glands of the cervix, and also in similar struc- 
tures of the uterine body. Of the different anatomic varieties, 
the squamous cell of the portio vaginalis is the most frequent. 
Next in order of frequency is the cylindric-cell cancer of the cer- 
vical canal, while the least frequent is the cylindric-cell cancer of 
the uterine cavity. Carcinoma of the uterus ranks in frequency 
next to cancer of the stomach. In 31,482 cases of carcinoma 
Welch found 29.5 per cent, were of the uterus. Williams estimates 
that death from cancer in women over thirty -five years of age is 
one in thirty-five. In a survey made by Dr. P. B. Bland of the 
vital statistics of the city of Philadelphia extending over a period 
of twenty-five years, from 1878 to 1903, 9777 women were found 
to have died from cancer. Of this number, 3172 were attributed 
to cancer of the uterus, 2139 to cancer of the stomach, and 1776 
to cancer of the breast. These statistics demonstrate the greater 
frequency of uterine cancer. During this period 1980 men died 
of gastric cancer, making a total from cancer of the stomach in 
males and females of 4 1 1 9 . Thus it is demonstrated that cancer of 
the uterus is by far the most common form of malignant disease, 
and it is for this reason that twice as many women as men die 
from cancer. The squamous-cell form of carcinoma is by far the 
most frequent malignant disease of the uterus — m^ore frequent, 
indeed, than adenocarcinoma of the cylindric form of disease in 
both the cervix and body. The squamous-cell variety develops 
from the atypical proliferation of the squamous epithelium cover- 
ing the vaginal portion of the cervix. In women who have borne 
children and in whom repeated lacerations of the cervix have oc- 
curred, cicatricial changes may lead to the extension of the squa- 
mous epithelium some distance into the cervical canal, and this 
explains the occasional existence of the disease some distance 
within the cervical canal, and that mixed forms not infrequently 
are present. 



746 GYNECOLOGY. 

632. Development of Squamous-cell Carcinoma. — This form 
of malignant disease may develop on the anterior or posterior lip 
of the cervix and frequently on the site of an old laceration. 
Cullen distinguishes three stages, according to the degree of in- 
filtration and disintegration of the part affected : (i) A rapid pro- 
liferation of the squamous epithelial cells : the lesion appears first 
as small, papilla -like nodules, hard at the base, more or less 
friable on the free surface, which bleed easily on examination. 
They present a glistening, bluish-white appearance on the surface, 
and on section tAvo zones are recognized — the first or peripheral is 
composed of a more or less friable, brain-like consistence and of a 
yellowish-gray, brain color. The second or basal zone lies in 
juxtaposition to the cervical tissue, is of a yellowish-white color, 
and of a dense, cartilaginous consistence. Close inspection of these 
nodules reveals fibrous striations or trabeculae occurring through- 




Fig. 510. — Squamous-cell Carcinoma of Cervix. 
a, Cervical canal; b, portion of vaginal wall involved in the malignant process. 

out their tissues. These bands surround or isolate nests of friable 
homogeneous tissue, the so-called cancer assemblages or cancer 
nests. These areas may be emptied of their contents by com- 
pressing the tissue, and small shallow depressions remain. It is 
important that such areas be not confounded with dilated cer- 
vical glands containing inspissated mucus — the so-called Naboth- 
ian cysts. The small papillary projections or processes manifest 
in the nodules grow and spread rapidly, forming a large cauli- 
fiower-like mass. Such a neoplasm has been designated the 
cauliflower cancer. In this stage the disease may be so extensive 
as to fill the entire vaginal vault. The extension of the papillary 
process into the vaginal wall appears a determination of the 
malignant disease to follow nature's law and travel in the line of 
least resistance. While this external proliferation occurs, there 
is a simultaneous invasion and consequent involvement of the 
subjacent tissue, which becomes dense, hard, and indurated. 



GENITAL TUMORS. 747 

Section of this nodule reveals the neoplasm appearing as a hard, 
cartilaginous, yellowish-Avhite gro^^i:h extending upward toward 
the internal os, and outward toward the vaginal vault, and later, 
also, in the directio|i of the parametrial tissue. Such neoplasms, if 
closely inspected, disclosed glistening trabeculae of fibrous tissue, 
constituting the stroma, which formed the walls or spaces in which 
assemble the parasitic epithelial cells. Thin sections made from 
such an area when compressed and washed out present a sieve- 
like structure. It is unfortunate that squamous-cell epithelium 
in this stage is so frequently undiscovered. It is rare, indeed, and 
usually only by accident, that the disease is recognized in this 
formative stage, as it is then wholly devoid of symptoms. It is 
at this stage that radical treatment w^ould present better results 
than now obtain, because the lesion is then most probably con- 
fined to the uterus. (2) The stage of moderate disintegration of 
decided symptoms and the period at which the disease most 
frequently comes under observation. The palpating finger will 
discover at this period the partial or total destruction of the cervix, 
and substituted therefor an irregular, cauliflower, fimgating mass 
of tissue of a gra^ash-yellow color, friable and brain-like in con- 
sistence. The tissue breaks down under manipulation and 
bleeds freely. Instead of the cauliflower mass, which may have 
disappeared by sloughing, a large, irregular, crater-like ulcer 
exists, the floor and sides of which are irregular, hard, and covered 
with a sloughing, gangrenous tissue. The disease will be recog- 
nized as having invaded the structures beyond the cervix, and the 
latter organ may have been to a great degree destroyed. After 
the removal of the uterus, the base of such an ulcer appears to be 
composed of a yellowish -white, hard, cartilage-like tissue. This 
tissue ramifies the structure of the cervix by finger-like projec- 
tions, as in the cauliflower growth. The disease extends, in- 
volving the vaginal vault and connective tissue of the broad lig- 
aments. The third stage is characterized by extensive or com- 
plete disintegration of the cervix and the involvement of the cir- 
cumjacent structures. It is usually recognized from the history 
and physical symptoms alone, without a vaginal examination. 
Palpation reveals an entire destruction of the cervix, and at its 
site a cone-shaped, sloughing, crater-like cavity. This has been 
described by some as resembling the cavity of a decayed molar 
tooth, its w^alls and floor covered with necrotic tissue. In pal- 
pation the tissue feels hard, granular, and presents numerous 
elevated nodules due to the presence of these finger-like processes. 
The disease reaches first that portion of the vaginal wall most 
contiguous to the original nodules. It is generally first upon the 
sides, then the anterior, and lastly the posterior, wall. With the 
invasion of the parametrium the broad ligament becomes hard 



748 GYNECOLOGY. 

and dense, the bladder becomes adherent to the uterus, and the 
disease extends into its wall. The ureters are frequently sur- 
rounded by masses of this infiltration, and finally become in- 
volved therein. Fistulous communications may take place be- 
tween the vagina and bladder and rectum. The disease may 
extend upward into the cervical canal as well as outward, but this 
course is less frequent. 

633. Histology of Squamous-cell Carcinoma. — The histologic 
picture of this disease depends upon the stage at which it is 
subjected to microscopic study. In primary proliferation and 
induration previous to disintegration, several characteristic 
elemental changes are observed. The tissue . secured for study 
should be so excised as to secure both healthy and diseased tissue, 
and the sections made therefrom should include both. The 
section of this tissue near the margin of the growth appears under 
the microscope similar to tissue showing a reactionary inflam- 
matory change. Small round-cell infiltration and polynuclear leu- 
kocytes are present. As the edge of the neoplasm is approached, 
disturbances will be noted in the squamous epithelium. These 
occur in the form of piling up or proliferation outward of the 
cells. Occasionally a superficial loss Avill be seen, but always is 
seen an ingro\\i:h or dipping down of the cells in cone-like proc- 
esses into the cervical tissue. The mucous covering of the cervix, 
as a rule, remains intact until the growth is well advanced. It 
will be seen that the invasion of the parasitic cells is not limited 
to one line of the stratified squamous epithelium alone, but that 
all layers take part in the process and that the normal basal layer 
of large cuboidal cells forms the boundar\^ of the advancing 
column. If the section extends through one of the finger-like 
processes, these cuboidal cells will be seen as forming the outer 
zone. The finger-like projections external to the line of cuboidal 
cell are surrounded by a network of fibrous tissue, which contains 
some muscle-fibers and is known as the stroma. In some areas 
keratinization or hardening of the central portion or even of 
nearly all of the epithelial nests is seen. These areas are the so- 
called epithelial pearls, which are of a yellowish color and dis- 
posed in layers resembling an onion. Epithelial pearls, however, 
are less numerous in the squamous-cell epithelioma of the cervix 
than in the same form of disease in other tissues of the body. 
This is incident to the fact that one layer of epithelium in the 
cervix is less well developed and often entirely absent. Active 
nuclear division in the parasitic cells is especially prominent. 
One characteristic of these wandering cells is the increased amount 
of coloring-matter (chromatin) found in them. Cullen asserts 
that the pathologic diagnosis can be determined by this and the 
increased size of the cells. The cells vary in size, but are generally 



GENITAL TUMORS. 749 

somewhat enlarged. The fibrous stroma enveloping the assem- 
blage of cells, the cell-nests, is composed largely of fibrous tissue. 
It contains, however, a few muscular fibers and springs from the 
normal cervical tissue. Throughout this stroma, in varying 
amount, will be seen round-cell infiltration. It is most marked in 
the margins of the growth and is due to the irritation of the invad- 
ing neoplasm upon the circumjacent tissues. The appearance of 
inflammatory cells about the margins of the gro^vth is an apparent 
effort upon the part of nature to construct barriers against the 
invading hostile cells. This round-cell infiltration is especially 
marked in cases where the development of the neoplasm is slow, 
while in those in which the growth is rapid the round-cell infiltra- 
tion is slight. In other words , nature is overwhelmed by the rapid 
progress of the disease and has no time to erect its defensive 
barriers. In the fibrous stroma are situated the blood-vessels, 
lymphatics, and nerves. The stroma is variable in amount, and 
depends upon the rapidity of the growth. In tumors of rapid 
growth it is more frequently indefinite, the tumor being largely 
cellular. A malignant tumor of this variety grows in two direc- 
tions: I, as an ingrowth and invasion of the cervical tissue 
proper; 2, as an outshoot or outgrowth of both stroma and cells, 
forming the cauliflower mass. 

In the later or middle stage of development, the stage of 
moderate disintegration, the disease appears under the micro- 
scope to invade tissue to a greater degree, but the margin of the 
growth shows the same histologic picture as seen in the earlier 
stage. The older portion of the tumor betrays the changes 
incident to necrosis and is found covered with broken-down 
tissue, blood, and detritus, welded together by fibrin. The tissue 
immediately beneath this older growth discloses more or less 
degenerative change. As the disease progresses, hyaline degen- 
eration occurs in the cells, both in the protoplasm and nuclei, 
and in some instances giant-cells will be found. In the stage of 
disease with marked destruction of tissue the necrosis and dis- 
integration changes are more marked. The cell-nests are fre- 
quently broken down and contain necrotic tissue and pus. 

634. Adenocarcinoma of the Cervix. — Cylindric-cell cancer or 
adenocarcinoma of the cervix finds its origin in the mucous 
membrane lining the cervical canal between the internal and the 
external os, and may arise either from the epithelium of the sur- 
face or from the cells lining the glands. It has been a greatly 
disputed question whether cancer of the cervix arises from the 
cover epithelium or the gland. Some contend that it arises from 
the free surface epithelium, while others that it has its origin 
from the epithelium of the glands. Winter asserts that the dis- 
ease most frequently develops from the combined point of origin 



750 GYNECOLOGY. 

of the glandular and surface epithelium, but it is now generally 
accepted that this form of malignant disease may originate in 
either one of these structures. The disease presents itself in a 
number of forms — sometimes occurs as a rounded nodule which 
may involve almost the entire cervix before disintegration results. 
It may appear in the lumen of the cervical canal in the form of 
tubercles, nodules, or papillary gro^\i:hs which fill up the cavity or 
are extruded from the os, while the external surface of the cervix 
is scarcely involved. Not infrequently the entire cervical canal 
is involved in the cancerous process without any pathologic 
changes being manifested outside the external os. The growth 
often appears as a hard, firm, waxy mass. In other cases ex- 
tensive inflammation of the diseased mucous membrane as well 
as of the muscle and cervical wall follows, causing thickening 
and hardening of the entire cervix. The carcinomatous nodule 
or nodules gradually undergo necrosis, leaving a sloughing, crater- 
like cavity in place of the cervical canal. When the disease is 
confined to the upper part of the cervical canal, it may remain 
for a time totally unsuspected, because it is hidden behind an 
uninvolved external os. As the disease progresses it gradually 
extends downward and creeps through the external os, but much 
more frequently has broken through the cervical wall into the 
parametrium before any change is manifest at the external os. 
The growth may be fairly well developed before the vaginal 
portion of the cervix exhibits any indication of its existence. 
Palpation at this stage discloses the organ to be hard, gritty, and 
nodular. Occasionally a fungus-like mass projects from the ex- 
ternal OS. A section through the cervix in this form of disease dis- 
closes an advanced stage and a condition resembling a worm-eaten 
cavity. With the disintegration of the carcinomatous tissue an 
extensive excavation is formed, which enlarges the external os in a 
fissure of considerable breadth. A large portion of the cervical 
canal may thus be disintegrated. This description indicates that 
the extension in adenocarcinoma differs essentially from that in 
the carcinoma of the portio vaginalis. In the latter, as has been 
indicated, the invasion is superficial. Ulceration follows early, 
but in the cylindric-cell cancer of the cervix the invasion rapidly 
penetrates the cervical wall into the parametrial connective 
tissue, while the vaginal portion of the cervix is involved late, if 
at all. Extensive invasion and degeneration of the cervical canal 
occur without any break in the continuity or any disturbance 
in the appearance of the squamous epithelial covering of the 
portio vaginalis. When one considers the changes which the 
cervix undergoes as a result of extensive glandular inflammation, 
when the whole cervical wall is involved in cystic degeneration 
from obstruction of the ducts of the cervical glands, it is easy to 



GENITAL TUMORS. 751 

appreciate how the mahgnant growth in such a field would 
rapidly penetrate to the parametrial structures before becoming 
evident in the vagina. The disease occasionally extends down- 
ward, involving the vaginal walls, but its usual direction is to- 
ward the body of the uterus and outward into the parametrial 
tissue. It occasionally passes through the internal os and in- 
volves the mucous membrane of the uterine body. Only a small 
portion of the uterine endometrium may be thus invaded or the 
entire mucosa. Occasionally the uterine mucous membrane may 
be the seat of isolated cancer-nests, the result of metastasis. In 
the progress of the disease it may penetrate to the peritoneum, 
but the vesicocervical septum is much more frequently involved, 
extending to the bladder and surrounding the lower ends of the 
ureters with masses of infiltration. The ureter is probably more 
frequently involved in this form of malignant disease than the 
bladder, for in attempting to remove the disease I have frequently 
been compelled to excise portions of one or both ureters in order 
to afford a hope of the removal of the involved parametrium. 
The infiltration about the extremities of the ureters causes ob- 
struction to the flow of urine and dilatation of the ureter and 
pelvis of the kidney, producing hydronephrosis, and when asso- 
ciated with infection, pyonephrosis. The extension of the dis- 
ease to the bladder and ureters, and backward to the rectum, 
with disintegration and ulceration, may produce fistulous com- 
munications by which the contents of the bladder and the rectum 
pass into the vagina. The posterior cervical wall and its en- 
veloping peritoneum are not so frequently involved in cancer of 
the cervix, but more frequently than when it originates in the 
portio vaginalis. Extensive peritonitis is infrequent, as the in- 
vasion of the disease is preceded by inflammatory barriers. Oc- 
casionally, however, perforation may result and a suppurative 
peritonitis follow. 

635. Histology of Adenocarcinoma. — The term adenocarci- 
noma will imply that the structure is of a glandular character. 
The disease generally develops in the glandular epithelium, 
although it may sometimes originate in the cover epithelium. 
The epithelium lining the glands proliferate, projecting into and 
filling up the lumen of the gland as small processes. . These pro- 
jections unite with one another and in this manner one gland may 
be subdivided into fifteen or twenty smaller glands. The epi- 
thelial cells lining the glands are ^tall, columnar, narrow, and 
somewhat irregular in size. The cell nuclei are generally located 
at the base of the cell, but occasionally are found near the center. 
When a tendency of the cells to form new glands exists, the epi- 
thelial cells will be seen piled upon each other. It is often dif- 
ficult, according to Waldeyer, to trace the connection of the 



752 GYNECOLOGY. 

carcinomatous growth with the orifice of the gland, yet he has 
secured sections demonstrating such connection. Ruge and 
Veit have shown that the glandular epithelium which ordinarily 
consists of but one layer becomes several layers thick, and that 
the original arrangement of the epithelium is lost. This feature 
of the disease is always evident, and the parasitic cells, when com- 
pared with cells lining the normal glands, will be seen to have 
special characteristics of their own. The first tendency to pro- 
liferation is intraglandular, the cells piled over each other, form- 
ing several layers in which intraglandular out shoots are pro- 
jected, dividing the original gland into numerous compart- 
ments. Extraglandular proliferation occurs later. The base- 
ment membrane is fractured, followed by a wide proliferation 
and projection of the epithelial cells into the interglandular 
fibrous stroma. The interglandular proliferation may be so 
extensive as completely to fill the gland lumen. Cross-sections 
of such occluded glands appear under the microscope as similar 
to epithelial nests found in squamous -cell carcinoma. When 
papillary projections appear from the external os, they will be 
found microscopically to be composed of papillae covered with 
one or more layers of cylindric epithelium. The stroma structure 
supporting these processes will be found more fully developed than 
that which exists in the squamous-cell carcinoma. Generally 
the epithelial cells of adenocarcinoma of the cervix decidedly 
differ morphologically from those seen in the cervical epithelium. 
Active nuclear division is always well marked. The stroma has 
its origin in the cervical tissue and is usually infiltrated with 
small round cells. The inflammatory infiltration in adenocar- 
cinoma is not so marked as when this process occurs in the squa- 
mous-cell epithelioma. This may be accounted for by the rapid- 
ity with which the adenocarcinoma develops. As the tumor 
matures, interference with its nutrition results, which is followed 
by necrosis and sloughing. The older portion of the tumor, 
therefore, is often covered with disintegrated tissue, and im- 
mediately under the surface, for a considerable depth, marked 
necrosis will be seen. 

636. Adenocarcinoma of the Body. — In the body of the uterus 
adenocarcinoma has its origin in the mucous membrane lining 
the interior of the uterine cavity, and arises either from the sur- 
face of the epithelium or from the epithelial lining of the tubular 
glands. This is the rarest form of epithelial malignant disease 
of the uterus, and is more likely to occur in women later in life 
or in those who have not borne children. As it more frequently 
occurs in women following the climacteric, it is the most hopeful 
of the different varieties of uterine carcinoma. The disease 
may originate at any point in the uterine cavity from the internal 



GENITAL TUMORS. 753 

OS to the fundus. It is unusual for the neoplasm to extend to- 
ward the internal os, and rarely does it reach the external. There- 
fore, in making a positive diagnosis it is necessary that the uterine 
cavity should be dilated to permit of its exploration with the finger, 
and frequently the diagnosis can be confirmed by the examination, 
under the microscope, of the scrapings and fragments removed. 
The disease may begin as a circumscribed nodule, springing from 
the surface of the mucous membrane, which consists of several 
delicate papilla-like processes. These processes may be irregular 
and wart-like in appearance, and the surface of the growth ap- 
pear perfectly smooth. This is particularly true in the early 
stage of the development, and the disease at this period may 
appear simply as a localized hypertrophy of the endometrium. 
The nodule gradually increases in size, and about its base, as the 
disease progresses, several smaller nodules will be found. Oc- 
casionally it may appear simply as a polypus with a very small 
pedicle. This growth may be so large as to fill up the entire 
uterine cavity. Such a growth may not be unlike the benign 
mucous polypus and consequently be confused with it. It is 
usually, however, more fragile and its surface less smooth. The 
proliferating mass is also much larger in comparison with 
the size of its pedicle than is found to be the case in the benign 
growth. It is probable that these malignant polypi develop 
from the infection of distended uterine glands, or they may be 
produced by the malignant transformation of a benign mucous 
polypus. Epithelial malignant disease of the endometrium gen- 
erally begins as a localized growth, although occasionally the 
lesion, even in its earliest stages, simultaneously involves the 
entire mucous membrane. As it progresses, outshoots or finger- 
like projections are produced, which grow in the line of least re- 
sistance — that is, into the uterine cavity, gradually filling it. Such 
a uterus will be found enlarged, soft, and more or less boggy, and 
a digital examination of its interior will reveal the cavity com- 
pletely filled with a soft, friable, grayish-yellow, brain-like tissue. 
This tissue is broken off and, displaced by the examining finger, 
makes its exit through the external os. Such a uterus com- 
pressed between the fingers within the vagina and the hand over 
the abdomen will oftentimes allow the discharge of disintegrating 
material. With the proliferation into the uterine cavity there is 
also a corresponding invasion of the uterine wall, although this 
is not so rapid. Section through the involved uterine wall or 
the basal portion of the tumor reveals a structure of more or less 
dense and firm consistence and of a yellowish- white color, which 
projects distinctly from the muscle. The growth gradually pro- 
jects through the uterine wall and may present beneath the 
peritoneal surface. As it advances and ages interference with its 

48 



754 



GYNECOLOGY. 



nutrition results and necrosis and disintegration of the older or 
superficial portions of the tumor follow. This necrotic material is 
gradually discharged and a scooped-out, crater-like cavity forms 
the uterine interior. The foul-smelling vaginal discharge is pro- 
duced by the necrosis of the tissue. 

Occasionally the cervical canal becomes completely occluded 
by the malignant growth, resulting in the accumulation of dis- 
integrating necrotic tissue within the cavity of the uterus, form- 
ing a pyometra. 

637. Histology of Adenocarcinoma of the Body of the Uterus. 
— The microscopic picture presented by adenocarcinoma of the 
body of the uterus seems to differ in almost every specimen 




Fig. 511. — Squamous-cell Epithelioma of the Uterus. 
o. Keratinization of cells forming epithelial pearls, b. Connective-tissue mat- 
rix, c. Collection of atypical cells. 

examined. These differences occur in the epithelial cells cover- 
ing the surface of the endometrium and in those lining the glands. 
In the early stages of the disease occurs a piling up or stratification 
of the cells, which may be localized. These local proliferations 
gradually increase in size and project into the uterine cavity. In 
the interior of the nodules is found a well-marked supporting 
structure, composed of fibrous tissue containing muscle-fibers 
which convey the nutrient vessels. These nodular projections 
vary in size. Some are short and some are long-drawn-out bodies 
which resemble somewhat the benign papilloma, but the cells 
covering the papillary projections are characteristic, and one of 



GENITAL TUMORS. 



755 



their strong features is the increased amount of coloring- matter 
they contain. The cells covering the processes are, as a rule, 
irregular in size, and very rarely, indeed, are they found uniform. 
The cellular irregularities are marked throughout the tumor, 
some appearing short and others quite long. The epithelium 
covering the projections may be arranged in a single layer when 
the cells remain cylindrical. As a rule, more than one cell cover- 
ing is noted, and the secondary layers are polymorphous in 




Fig. 512. — Adenocarcinoma of the Cervical Canal. 
a. Cervical canal, b. Shows extension of disease to internal os. c. Hypertrophied 

endometrium. 



character. In other instances the picture presented under the 
microscope is more of the adenoid type, and the histology of the 
neoplasm is similar to adenoid carcinoma found in the cervix. 
Numerous glands are found of varying size, lined with colum- 
nar epithelial cells. These are irregular and contain oval, 
deeply staining nuclei. The cells lining the glands may be dis- 
posed in a single layer, but in many areas an intraglandular piling 



756 GYNECOLOGY. 

Up or stratification of the cells will be seen, and in other areas 
fracture of the limiting membrane with an extraglandular pro- 
liferation of the cells is recognized. In these areas the cells will 
be found wandering in the fibrous stroma between the glands, 
and this perhaps is the distinctive stamp of the true malignant 
character of the tumor. Cullen believes that in those cases 
characterized by marked papillary arrangement the growth is 
started in the surface epithelium; whereas in the cases having 
distinct adenoid arrangement, the epithelium lining the glands 
has possibly been their origin. As the disease ages there is a 



..,:,.. .^,M.^ tm 



\ m 






:^?®^'^'^^^-S*^^„. 0^f: 










.;.-/'^%' 










Fig. 513. — Adenocarcinoma of Body of the Uterus, 
a. Cells fracturing basement membrane and infiltrating fibrous stroma, h, b, b. 
Intraglandular proliferation of cells, c, c. Irregularity of cells, d, d. 
Epithelial cells infiltrating stroma. 



breaking down of the peripheral portion of the growth; the sur- 
face undergoing destruction shows marked inflammatory in- 
filtration, and the gland in the deeper portions of the tumor may 
show degenerative changes. iVs the necrotic process advances 
degeneration of the uterine muscle takes place and both muscle and 
glands are filled with inflammatory cells. 

638. Dissemination of Carcinoma. — Carcinoma is not con- 
fined in its development to the infiltration of the contiguous 
tissues already described, but manifests a disposition to spread 
through the lymphatics and blood-vessels to the structures more 
or less remote from that in which it originated, and here to form 



GENITAL TUMORS. 757 

foci or nests of a similar character. Experience demonstrates 
that this spread of the disease through the blood-vessels is rare. 
Malignant tdceration of the blood-vessels, however, does take 
place, and metastases follow through the blood stroma. Seelig 
directed attention to the fact that the capillaries for a long time 
remained intact between the existing carcinomatous projections. 
He once saw a carcinoma ring around a vein which had infected 
the wall of the capillary up to the intima. Goldman has ob- 
served penetration of the thin walls of the vein by cancer with 
alteration of the lining endothelium. In this case circulation 
was obstructed, with the formation of a thrombus. Abel recites 
the history of a patient, thirty-seven years of age, who had suf- 






Fig. 514. — Cauliflower Growth Involving the Vaginal Part. 

fered two months with irregular bleeding and discharge. Ex- 
amination failed to reveal any indication of involvement of the 
vaginal wall or parametrium. Total extirpation of" the uterus 
through the vagina was done, with as extensive removal of the 
broad ligament as possible. Subsequent microscopic investi- 
gation disclosed at some distance from the carcinoma, in a per- 
fectly healthy looking area, a mass of carcinomatous tissue 
which infiltrated the wall of the vein. The occurrence of such 
conditions demonstrates the possibility of the transmission of 
carcinomatous masses through the blood stream. The principal 
method of extension, as already mentioned, is, however, through 



758 



GYNECOLOGY. 



Fundus. 



the lymph-channels. The epithelial cones project into the con- 
nective-tissue folds until they gradually reach large lymph- spaces. 
Having reached one of these spaces, it rapidly extends itself. 
The more rapid development of the disease in pregnant women 
is undoubtedly caused by the increased size of the lymph-channels 
and the increased energy of the lymphatic circulation at this 
period. All observers recognize the rapidity with which malig- 
nant disease invades the tissues when it has developed in young 
women. This is undoubtedly due to the activity of the lymph cir- 
culation. Following the 
climacteric, and especially 
in senile women, the vessels 
become atrophied and small. 
The lymphatic circulation of 
the pelvis is very inactive. 
In such individuals, there- 
fore, the disease spreads 
slowly, and it is only when 
the deeper structures have 
undergone infiltration that 
the lymph-spaces are opened 
and the disease is more 
rapidly transmitted. Seelig, 
in his careful investigations 
on the progress of the dis- 
ease, noticed the projection 
forward of carcinomatous 
masses into the endothelial 
lining of the lymph-spaces. 
These masses more or less 
obstruct the large vessels, 
although the vessels them- 
selves could still be recog- 
nized in the structure. The 
largest lymph-spaces filled 
with carcinoma were situated in the margin between the middle 
and peripheral muscle layer of the corpus uteri, while the inter- 
nal muscular branches anastomose vertically. Investigation 
demonstrated that carcinomatous masses press against the con- 
nective-tissue or muscle-fibers until they are able to invade 
the lymph-spaces. Obstruction of the lymph- vessels not infre- 
quently results in a regurgitation, by which portions of the 
malignant tissue are carried backward in the lymph-spaces in a 
direction opposite to that of the normal current. The invasion 
of the anterior wall of the vagina with cancerous disease, when it- 
has originated in the cavity of the uterus, maybe thus explained. 




Fig. SI5. 



-Cancerous Ulceration of Intra- 
cervical Canal. 



GENITAL TUMORS. 



759 



As the disease enters the lymph-spaces it is carried by the larger 
paths into the parametrium, where the lymphatics are not infre- 
quently filled with carcinomatous masses. Emboli are carried 
from the lymph-spaces into the next lymphatic glands without 
the vessels themselves being involved. While it is generally 
recognized that the principal channel of invasion is through the 
lymph- vessels, yet it seems apparent that malignant disease of 
the uterus produces lymph-gland involvement at a later date 
than in cancer of other portions of the body. The later trans- 




Fig. 516. — Cervical Wall Infiltrated while the Vaginal Portion is Largely Des- 
troyed. 

mission of the disease to the lymph-glands is undoubtedly due 
to the more frequent occurrence of the disease at or subsequent to 
the climacteric, when the lymph-ducts of the pelvis have become 
atrophied as a result of the lessened activity of the genital organs. 
In women under forty years of age, however, this does not exist, 
and it is in these patients in whom the disease makes the most rapid 
progress and the prognosis for cure is most unfavorable. Aluch 
difference of opinion exists among investigators in this field as 



760 



GYNECOLOGY. 



to the frequency of glandular involvement, and necessarily the 
decision of this question has an important bearing upon the plan 
of treatment. Ries, Pry or, Wertheim, and others assert that as 
a result of careful investigation they have found a large propor- 
tion of the next lymph-glands infected A^ery early in the progress 
of disease. Schauta concurs in the frequency of gland infection, 
but insists that it is the deep or inaccessible glands which are 
generally involved, and frequently at a time when those next 
are unaffected. Those who doubt the early gland infection 

point to the number of cases in 
which the operation by either 
the abdomen or the vagina has 
been followed by failure of the 
disease to recur for so long a 
period as to justify the assertion 
that the patient is cured. When 
recurrence follows, it in the ma- 
jority of cases is found in or near 
the vaginal scar and not in the 
lymph-glands . Experience would 
seem to indicate that the involve- 
ment of the glands is not neces- 
sarily followed by recurrence of 
the disease. The removal of the 
original source is evidently in 
some cases followed by atrophy 
of the infected glands. 

CuUen accounts for the failure 
to involve the lymphatic glands 
as early in carcinoma uteri as 
in mammary carcinoma, by the 
fact that in the uterine disease 
there is a greater disproportion 
between the size of the epithelial 
cells and the lymphatic vessels, 
that the epithelial cells rapidly 
attain a size too large to permit 
of their passage through the lymphatic vessels, and it is only 
after the disease has reached the large lymphatic spaces and 
vessels that lymphatic gland infection occurs. The investiga- 
tions of Blau and Dybowsky particularly emphasize the infre- 
quent involvement of lymphatic glands in women who have 
died from cancer in the Berlin Charity. The former found 
the lymph-glands of the pelvis involved but thirty times in 
ninety-three sections, while the latter in one hundred and ten 
cases found only ten of lymphatic infection. In cancer of the 




Fig. 



517. — Circumscribed Cancer of 
Body of Uterus. 



GENITAL TUMORS. 



761 



cervix Blau found the lymphatic glands infected in scarcely 
one-third of the cases. The experience of operators would seem 
to confirm the claim of the majority of investigators that lymph- 




Fig. 518. — Diffuse Cancer of Uterine Body. 




Fig. 519. — Adenocarcinoma of Uterine Body. 



762 



GYNECOLOGY. 



atic gland involvement occurs much later in uterine cancer than 
in other portions of the body. 




Fig. 520. — Incipient Adenocarcinoma of Uterine Mucous Membrane. 
a. Carcinomatous nodule. 




Fig. 521. — Entire Cavity Covered with Nodular Growths. 



639. Clinical Forms. — We have already seen that cancer 
is divided, from a histogenic standpoint, into two forms, the squa- 
mous-cell and the cylindric-cell cancer; clinically it is divided 



GENITAL TUMORS. 



763 



into carcinoma of the portio vaginalis, of the cervix, and of the 
body of the uterus. It is still further divided clinically accord- 
ing to the course that the disease pursues and the physical 
signs presented. Thus, a collection of epithelial masses may 
break down upon the involved surface or in its center. The 
growth can project from the portio vaginalis into the lumen of 
the vagina, or, at the same time, the connective tissue of the 
portio is occupied by the stroma and penetrated to its depth by 
cancer masses. These masses most frequently develop in cancer 
of the portio above the level and toward the lumen of the vagina, 




Fig. 522. — Communication between Bladder, Vagina, and Rectum. 



by w^hich is formed a superficially situated tumor known as a 
cauliflower growth. It exists as a more or less roundish, polypoid 
tumor in the vagina, completely distending it, and presents a 
tumor the size of a fist, which becomes more contracted and 
firmer as the healthy structure is approached. The surface of the 
cauliflower, after desquamation of its pavement epithelium, re- 
veals exposed carcinomatous masses and presents an irregular or 
papillary condition. When the disease has had a longer duration, 
with unfavorable nutrition of its interior stirface and with com- 
pression of its vessels, large portions become necrotic and the 
cauliflower gro^vth is covered with a grayish, greenish, smeary 



764 



GYNECOLOGY. 



mass. Such gro^vths most frequently originate in the posterior 
lip. In many cases the disease develops in one commissure and 
extends from it to the lip ; rarely the entire portio vaginalis is 
simultaneously degenerated. In other cases processes of epithe- 
lial growth project into the substance of the portio, and in deep 
infiltration there is thickening of one lip of the commissure. In 
rare cases the entire portio vaginalis becomes involved and the 
more affected lip grows toward the lumen of the vagina. This 
form differs from the cauliflower growth by being polypoid and 
by having a mucous membrane drawn over it, which is rarely 
quite intact. Frequently the mucous membrane is thrown oft 

in superficial layers and is followed by 
disintegration of the surface of the infil- 
ls -^ " — ^ ^^*'— I tration, or it begins in the center and 
\*^ ■ !^^|te /./ ')/ opens through the infiltration to the out- 
\i i .^^^^Bf fr 1/ side. A smooth funnel or fissure will 

thus be formed, with jagged, often 
undermined borders, sharply lying 
toward the circumference and appear- 
ing under the level of the healthy sur- 
roundings. In such a fissure an ulcer 
will occasionally dissect deeply into the 
portio. Movable polypoid tumors will 
project into the ulcer or around the 
cervical canal, without special alteration 
of the canal itself. (Fig. 523.) Smooth 
ulcers are occasionally observed, similar 
to the erosion, which extends to a very 
trifling depth. Why these variations in 
the progress of the disease exist is as yet 
undetermined. 

640. Etiology. — Our knowledge of 
the causes of malignant disease is still 
largely speculation. Among some of 
the more important theories as to its 
development are: Virchow's, that while cancer is of epithelial 
origin, it is only through metaplasia or mesodermal elements that 
it originates; in other Avords, a transformation of the connective- 
tissue cells. Cohnheim advocates the theory that it was trans- 
mitted from embryonic carcinoma germs. Riberts believed the 
epithelial cells separated from their connection without anaplasia ; 
Thiersch and Waldeyer, that by primary growth of the epithelium, 
without alterations of biologic properties of the epithelial cells. 
All agree that there is no distinctive cancer-cell. 

In recent years increased attention has been concentrated 
upon the determination of some micro-organism which shall 




Fig. 523. — Cervical Canal 
Destroyed by Progress 
of Disease. 



GENITAL TUMORS. 765 

prove to be a causative factor. Such a theory seems favored 
by the natural history of the disease, its local origin, its invasion of 
the surrounding structure, and its transmission by the blood- and 
lymph-vessels. The mere fact that a specific micro-organism has 
never been isolated' and recognized is not a convincing objection, 
for syphilis has baffled all attempts to recognize its essential 
organism, yet no one doubts that it is so transmitted. Klebs and 
others have presented various micro-organisms, but none of them 
have survived careful investigation. The presence of cancer 
results in the development of micro-organisms of various kinds, 
just as is found in other inflammatory processes, but none of 
them will reproduce the disease. Various degenerative proc- 
'esses in the cells have been indicated as possessing the parasitic 
elements, only to be proved untenable. Schwarz has most con- 
vincingly demonstrated that the majority of cell alterations 
favoring the parasitic theory have so far resulted from degenera- 
tive processes of the epithelial cells, leukocytes, or their deriva- 
tives. A fundamental pathologic difference exists in that with 
the malignant a further extension of the processes in the organ- 
ism is influenced by the cell activity, and there is as yet abso- 
lutely wanting any proof of isolation of a parasite from which 
the disease can be generated by its employment. The absence 
of any history of the transmission from man to animal or from 
one animal to another has been cited. 

The occinrence of carcinoma in the penis of the male who 
has cohabited with a cancerous female is so rare as to be the 
exception to the rule, yet these negative arguments are only 
additional evidence that we do not know the micro-organism or 
its natural history. Surgeons not infrequently injure themselves 
while operating, but no authentic case exists by which the 
development of cancer can thus be traced. Experimental ob- 
servations, however, have demonstrated the fact that carcinom- 
atous tissue when transferred from one animal to another of 
the same species will continue to grow, w^hile carcinomatous 
cells deA^eloping in the human individual when implanted in the 
tissue of another person may refuse to grow ; the tumor-cells when 
placed in a raw surface distant from the original site of the growth 
may develop a secondary tumor. I have operated upon patients 
for carcinoma of the cervix w^ho have subsequently developed 
secondary malignant disease of the abdominal incision. In one 
of them the disease developed nine months after the operation ; 
in another after a period of over three years. In the latter patient 
the abdominal scar was involved in a hard, indurated mass, 
which upon incision revealed the intestine adherent and its walls 
infiltrated with carcinomatous tissue. The abdominal scar was 
excised with the aft'ected intestine, and the patient made a com- 



766 GYNECOLOGY. 

plete recovery. There was no evidence of recurrence of the dis- 
ease in the pelvis at the time of operation. Evidently, increasing 
age predisposes the cell to carcinomatous degeneration. Statis- 
tics indicate that cancer of the uterus before the twentieth year 
is extremely uncommon and that it is but rarely observed during 
the next ten years. The disease perhaps makes its appearance 
most often immediately preceding or about the period of the 
menopause. Carcinoma of the body, however, usually appears 
later. Gusserow, in 3385 cases, found but 2 originating before 
the twentieth year. It develops with increased frequency during 
the fourth decennium, but the majority of cases are recognized 
in the fifth. Thiersch believed the greater frequency of cancer 
with advancing age was due to atrophy of the connective tissue, 
which favored the deeper infiltration of the epithelial tissue, but 
this is a mere hypothesis. Undoubtedly carcinoma occurs with 
much greater frequency now than formerly. Reyburn and 
Lewers attribute this to diet, and direct the attention to the in- 
frequency of this disease among rice-eating populations. They 
assert that the disease is largely due to the consumption of large 
quantities of meat. 

Heredity. — Inherited predisposition to the development of 
cancer has been regarded as an important factor, but careful re- 
searches by Gusserow showed but 7.4 per cent, favoring such a 
tendency, while von Winckel found but 6.3 per cent. Inherited 
lowered resistance to disease, as shown in families predisposed to 
tuberculosis and chronic renal disease, favors the development of 
malignancy. 

Sex. — Twice as many women suffer from cancer as men. Next 
to the mammary gland, the disease occurs more frequently in the 
uterus. According to Hofmeier, fully one -fourth of all cancers 
in women are uterine. 

Condition of Life. — Cancer of the uterus greatly preponderates 
in the poorer classes, in whom the feeble nutrition, great toil, and 
more exacting lives favor degenerative processes. 

Sexual Activity. — All statistics prove that malignant disease 
preponderates in those who lead an active sexual life, especially 
in the multiparous woman. Gusserow' s investigation of a large 
number of cases gave the average of fruitful labors in cancerously 
afflicted women as 5.1 per cent. — a proportion of births consider- 
ably above the average for women taken together. Accepting 
the irritation theory of Virchow as a factor, we can readily appre- 
ciate the greater frequency of cancer of the cervix. The possi- 
bility of cancer of the cervix in the chaste virgin has been doubted, 
but I have seen several single women of unquestionable virtue 
who suffered from cancer of the cervix. Cancer of the body of 
the uterus is comparatively more frequent in the unmarried and 



GENITAL TUMORS. 767 

nulliparous women. The theory that cancer can be produced by 
excessive coition is not borne out in the Hves of prostitutes. Car- 
cinoma may be secondary in the uterus, having originated in the 
bladder or vagina. Myoma of the uterus is sometimes associated 
with cancer, but not so frequently as to render it noticeable as a 
predisposing cause. Landau is inclined to assign syphilis as a 
predisposing cause, but my observation does not incline me to 
accept it. Von Winckel's assertion that gonorrhea is an im- 
portant factor in the development of cancer needs confirmation. 
With all our investigations we are driven back to irritation, 
chemical or mechanical, as a cause for malignant disease, but its 
existence does not always determine such a degeneration. We are 
forced to acknowledge that we do not know why cancer develops. 
641. S3miptoms. — Unfortunately, in the early stages no symp- 
toms, either subjective or objective, are sufficiently marked to 
give warning of the impending danger. As a consequence, the 
physician rarely has an opportunity for early investigation of the 
disease. Cancer has no pathognomonic signs; the principal 
symptoms — hemorrhage, more or less offensive discharge, and 
pain — are not constant in all cases, and each one or all may be 
produced by other than malignant conditions. Bleeding is the 
symptom of greatest significance, and may occur when the canal 
of the cervix is affected, though the vaginal margin is uninvoh^ed. 
The quantity of blood lost will probably be slight and irregular, 
as a few drops after severe exertion, straining at stool, or follow- 
ing the act of coition. In the married, post-coitive hemorrhage 
is a most constant and suggestive symptom. Generally the first 
intimation will be an increase of the amount of blood lost at 
menstruation, or the flow will be continued unduly long, but this 
is not constant. In other cases the first indication will be a 
profuse bleeding. After the occurrence of the climacteric, an 
occasionally more or less profuse bleeding will occur at intervals, 
which causes the patient to think that her menses have returned. 
Post-climacteric pudendal bleeding should always be regarded as 
a serious danger-signal until careful and painstaking examination 
has demonstrated the contrary. As the disease advances, hemor- 
rhage becomes more active, the blood is discharged in a continu- 
ous bright stream, or more frequently in large clots, which are 
formed in the vagina. Frequently the hemorrhage is accompa- 
nied by a discharge of fragments of disintegrating tissue. The 
continuation of hemorrhage produces marked anemia and pro- 
motes the cachexia, but is rarely the direct cause of death. 
Unfortunately, women generally regard increased and irregular 
bleeding as a necessary concomitant to the climacteric, a view 
which is maintained too frequently by the attending physician. 
On the contrary, any excess and irregularity in the flow should 



768 GYNECOLOGY. 

always be regarded as an indication of grave danger, demanding 
most thorough investigation of the genital tract, supplemented 
by microscopic investigation, if necessary, to ascertain the 
specific cause. Nothing should be taken for granted or left to 
chance. No palliative measures or remedies to arrest bleeding 
should be employed prior to an examination. If the physician 
is unable to satisfy himself as to the cause, duty to his patient 
demands that she shall have the benefit of further consultation. 

Offensive discharge is next to hemorrhage in the time and 
frequency of its appearance. In an early stage the discharge is 
slimy and serous and does not have an especially penetrating 
and offensive odor. As the disease advances and is associated 
with ulceration and disintegration of tissue, the secretion changes ; 
it becomes yellowish; then, with a mixture of blood and dis- 
integrating tissue, reddish and brownish; and, finally, a dark, 
smeary mass. At first it has a stale, sweetish odor, becomes more 
disagreeable, and finally presents an intensely penetrating, stink- 
ing smell, alike disgusting to the patient and to her attendants. 
When patients have suffered from cervical discharge possibly for 
years, little attention is given to the increase of the amount 
until the odor becomes so marked and disagreeable as to demand 
consideration, when it will frequently be found that the time for 
successful treatment has probably passed. Decomposition of the 
secretion is undoubtedly due to saprophytic or putrescent germs, 
and the greater accessibility of the cervix causes the odor of 
its secretion to become earlier affected than that of the uterine 
cavity. 

Pain is a comparatively late symptom. The cervix, as is well 
known, is not a specially sensitive structure, and the severe pain 
occurs with the involvement of the parametrium, and is later 
increased by pressure upon nerve-trunks. In uterine cancer, or 
when it involves the cervical canal, pain is more marked, and is 
an earlier symptom, owing to encroachment upon the internal 
OS and obstruction to the canal. The absence of pain leads many 
patients to regard the increased bleeding and discharge with less 
suspicion. When an effort is made to impress a woman so 
afflicted with the gravity of the situation, she will doubtingly 
exclaim: "Why, I have no pain!" Slightly extended nodules 
near the cervix, by pressure upon the nervous plexuses in the 
retroperitoneal connective tissue, may produce a lively, persistent, 
boring pain in the depth of the pelvis, which is increased to 
an extraordinary degree by the slightest extension. It causes 
persistent lancinating pain, which is not alleviated by continuous 
rest in bed, and only the persistent employment of narcotics 
affords any mitigation. As the disease approaches the peritoneal 
surface the pain is increased, serious reaction in the nutrition 



GENITAL TUMORS. 769 

is induced, from which inflammatory adhesions with the sur- 
rounding structures are the result, and an extensive peritonitis 
is thus caused. The abdomen is sensitive to pressure, and, 
according to Schroder, vaginal examination reveals the uterus 
surrounded by board-like hardness. Not infrequently the symp- 
toms may be aggravated by compression an^ narrowing of the 
rectum through advancing infiltration of the pelvic connective 
tissue. 

The mechanical obstruction to the passage of fecal masses is 
generally associated with severe, agonizing pain ; obstinate con- 
stipation arises, partly from the mechanical hindrance, but much 
more from the desire to avoid the severe pain at stool. In 
cancer of the neck of the uterus, when the disease is transmitted 
to the bladder- wall, even before the entire wall is penetrated 
there is a burning sensation during the evacuation of urine, soon 
followed by tenesmus, frequent micturition, bloody, clouded, or 
purulent urine, with persistent vesical pain. With the infiltra- 
tion and necrosis of the structure a direct communication follows. 
The admixture of ammoniacal urine with the offensive vaginal 
discharge aggravates the already lamentable condition of the 
patient by a horrible stench. The profuse, irritating vaginal 
discharge produces an extensive erythema of the vulva and 
inner sides of the thighs, and causes the patient to complain of 
the intense itching, or pruritus vulvas. 

The offensive character of the pudendal discharge may be 
still more aggravated when the disease involves the peritoneal 
surfaces of Douglas' pouch and is transmitted to the rectum and 
upper part of the rectovaginal septum, which breaks down and 
forms a rectovaginal opening. Occasionally, a large cloaca is 
formed, into which are discharged urine and feces, mixed with 
decaying tissue, and forming a m.ost deplorable condition. For- 
tunately, the rectum is less frequently involved than the bladder. 
Frommel asserts that vesical fistula appears in one-third of all 
cases, rectal fistula in one-sixth. In the progress of the cancerous 
infiltration on either side or in front of the cervix the ureters 
will sooner or later become involved. The infiltration extends 
about and compresses their lumina, attacks the structures of the 
wall, and may finally completely occlude it. So long as the 
passage of urine remains free, the patient experiences no ill 
effect, but the compression causes a gradual dilatation of the 
ureter and pelvis of the kidney; a condition of hydronephrosis 
follows, and indications of uremia. If but one side is affected, 
the other kidney does compensatory work, and, beyond a possible 
sense of fullness and weight in the affected organ, there is but 
little discomfort. When both organs are compressed, uremic 
symptoms follow, though never violent, rarely convulsive, and 

49 



770 GYNECOLOGY. 

gradual coma is developed, which causes increased indifference to 
surroundings, and, fortunately, to the profuse pain. Disgust for 
food is marked. Vomiting frequently occurs, and suppression of 
urine may be present. The condition has its compensation in 
that such patients are relieved by the coma from previously 
marked pain. 

Reduction in pressure from degenerative changes in the infil- 
tration will often restore the caliber of the canal and permit the 
urine to pass. The sensorium will become free and so continue 
until new compression symptoms appear. An autopsy frequently 
discloses above the cancer infiltration dilated ureters, sacculated 
kidneys, occasionally pyelonephrosis and amyloid degeneration 
of the kidney. Continuation of the infiltration processes causes 
obstruction of the veins and arteries of the pelvis with edema 
of the vulva and of the lower extremities. Hemorrhoidal veins 
become greatly distended and cause profuse bleeding. The re- 
sistance of the peritoneum to the encroachment of the disease 
is very marked. Its approach to the peritoneum is followed by 
reactive inflammation and extensive adhesions, so that cancerous 
nodules rarely reach the peritoneal cavity. Sepsis is also rare. 
When septic peritonitis is produced, it is caused by rupture, by 
pyosalpinx, or by penetration of the cavity from the cancerous 
nest. While sapremic symptoms are frequently associated with 
cancer, the temperature elevation is not high, for the reason that 
the disintegrating tissue is usually shut off from the general 
system by a zone of hard infiltration tissue, which is not very 
absorptive. When high temperature is present, it is generally 
due to an extension of the disease to other organs, especially the 
bladder. It is very important to ascertain the presence of metas- 
tasis to other organs. In the ordinary course of the disease it 
extends to the vagina, bladder, rectum, and vulva; but it may 
reach the same glands by metastasis, as well as the ovary and 
retroperitoneal glands. Metastasis may occur into rem^ote or- 
gans, as the liver, lungs, and kidney, although the number of 
cases in which wide diffusion occurs is comparatively few. 

Cancer affects the mature, debilitated, and overworked, but 
is also found in the well nourished, and not infrequently in the 
comparatively young. (Fig. 524.) -The disease in the latter is 
usually much more rapid in its course. Its mere existence is an 
evidence of lessened resistance to its ravages. In the early 
stages, with patients in good condition, the general appearance 
would contraindicate its existence; but with recurring hemor- 
rhage and discharge, emaciation rapidly occurs. Emaciation is 
more rapid when to the other symptoms is added pain, which 
robs the patient of her night's rest. To the drain from hemor- 
rhage and to the loss of rest is soon added the depressing effect 



GENITAL TUMORS. 771 

of the putrid changes, from a collection of organisms which exert 
a very painful influence upon the general condition. The skin is 
pale, and gradually becomes a smutty yellow from increased 
emaciation. The eyes are sunken and the skin is thrown into 
loose folds or appears to be drawn over the skeleton. A patient 
exhibiting such changes is said to be cachectic. The indications 
of suffering are stamped upon the countenance so indelibly as 
to be readily recognized by the experienced observer. From 
other conditions causing uterine hemorrhage, as myoma espe- 
cially, a cancerous patient is recognized by the tanned appearance 
of the skin and the progressive emaciation. In myoma she may 
become pale, anemic, and often yellow, but there is no loss of 
flesh. Indeed, the embonpoint seems increased. In cancer the 




Fig. 524. — Uterus Removed from an Unmarried Woman Twenty-two Years 

of Age. 

loss of strength is aggravated through the increased disgust for 
food occasioned by the foul-smelling atmosphere in which she is 
forced to live. Gusserow's view is undoubtedly correct, that the 
intense odor occasions the nausea and is made manifest by the 
return of appetite, when by any medical or surgical procedure 
this symptom is temporarily removed. Vomiting is generally a 
late symptom, and most frequently the result of uremia. Rarely, 
it may be occasioned by invasion of the peritoneum. The loss 
of strength and flesh is progressive, until finally the patient dies 
in profound marasmus. Occasionally, she suffers no convulsive 
attacks from uremia, but just sufficient coma to render her 
insensible to the discomfort of the condition. In some cases 
septic or carcinomatous peritonitis, pleurisy, pneumonia, lung 



772 GYNECOLOGY. 

embolism, or amyloid degeneration of the large glands leads to 
a premature end. 

642. Physical Signs. — In the previous discussion it has been 
asserted that carcinoma has no pathognomonic symptoms, conse- 
quently its early recognition will largely depend upon the correct 
interpretation of the physical signs. Unfortunately, the patient 
may have no symptoms affording such discomfort that she will 
feel it necessary to consult a physician, and, as a natural conse- 
quence, the disease will often be in an advanced stage before the 
patient comes under observation. Many patients do consult a 
physician, however, and are subjected to local treatment for 
other conditions than the grave one which should attract the 
attention of the observer, and valuable time is thus lost. It is 
to save these cases that, at the risk of reiteration, this section 
is written. The disease in many cases is hidden within the 
uterus and the physical signs consequently obscured. Fortu- 
nately, in the great majority of patients the disease affects the 
cervix and cervical canal. The squamous-cell cancer affects the 
external portion of the cervix and appears as a small tubercle 
or projection upon one or the other lip of the cervix. In the 
majority of cases a more or less extensive laceration of the 
cervix will be present. This tubercle will give the sensation to 
the examining finger of a shot-like mass, but manipulation of 
it is associated with slight bleeding and often the papule will 
be friable and can be broken off. As the disease advances the 
surface presents a superficial ulceration, which is above the level 
of the surrounding healthy structure. Its edges are prominent, 
infiltrated, ragged, often overhanging; its surface more or less 
excavated, covered with friable tissue, portions of which are 
easily broken off, and it has an infiltrated base. Pressure against 
such a surface with a sound permits the point of the instrument 
to become buried in friable tissue. The most careful examination 
is attended with bleeding. Frequently the vagina will be found 
occupied by a mass which may vary from the size of a filbert 
to that of a good-sized fist. Such a tumor presents an irregular, 
pinkish-gray surface, often covered with a greenish-yellow exu- 
date. The mass is continuous with one lip or the entire cervix 
may be involved. The surface has a granular, friable feel, will 
readily give way under the pressure of the finger or of an instru- 
ment, and is associated with a very offensive discharge. Adeno- 
carcinoma within the cervical canal may make extensive progress 
before it becomes visible. Even when invisible, the external 
portion of the cervix appears paler, gives a sensation of hardness 
or resistance to the examining finger, which is firmer and less 
elastic than when due to inflammatory exudation. The cervix 
will often feel hard and dense when carefully palpated, and the 



GENITAL TUMORS. 773 

pressure usually causes a discharge of blood from the os. Very 
frequently the existence of a laceration will permit access of the 
finger, which will reveal the presence of hard nodules, fragments 
of which are easij.y broken away. The surfaces instead may 
present a large mass of infiltration, the center of which has 
become necrosed, affording an excavation with infiltrated, over- 
hanging edges and a pultaceous, friable surface. In more ad- 
vanced cases the cervix may be a mere shell, a large part of 
the uterus being involved. The infiltration can be recognized 
to involve the walls of the vagina, the lumen of which is con- 
tracted by the disease. Carcinoma of the uterine body may be 
inaccessible to touch until well advanced, unless its uterine canal 
is subject to dilatation. Intra-uterine indagation reveals an 
outgrowth from a portion or the whole of the uterine cavity, 
which, soft and friable to the finger, rests upon a firm and 
indurated base. When the wall of the uterus is extensively in- 
filtrated, the increased resistance can be recognized by recto- 
abdominal palpation. The penetration of the uterine wall by 
the infiltrate is recognized in the nodules beneath the peritoneum, 
which roughen the otherwise smooth surface of the uterus. No 
discussion of the physical signs of carcinoma is complete without 
a consideration of the revelations of the microscope, but as they 
have been partially studied under the various forms of disease, 
and will be further under diagnosis, I will not discuss them here. 
643. Complications. — The more frequent complications of 
uterine cancer are myoma, ovarian tumor, peri-uterine inflamma- 
tion, and pregnancy. The myoma usually does, and the ovarian 
tumor may, precede the development of the carcinoma. Atten- 
tion has been recently directed to the association of myoma and 
carcinoma in the same patient (see Fig. 485), with some effort to 
indicate the causative relation; but with the great frequency of 
uterine myoma it would not be surprising should we find, even 
more frequently than is now recognized, the coexistence of car- 
cinoma. The disease begins in the uterine mucous membrane, 
and may subsequently extend and infiltrate the growth. The 
growth can be primarily affected only when there is included in 
it some glandular structure. It has occurred to me that the 
irritation induced by the prolonged use of electricity for its 
influence upon the fibroid growth may favor the development of 
malignant disease. I have seen carcinoma occur in two cases 
subsequent to the application of electricity, but the cases tinder 
observation have been so few that to make this assertion would 
be no more correct than to assign myoma as the cause of the 
cancer. Ovarian tumor may be benign or malignant. Benign 
growths may become secondarily involved. The cancerous tumor 



774 GYNECOLOGY. 

of the ovary, however, varies greatly in its influence and in its 
manner of progress from the benign. 

Peri-uterine Inflammation. — Peri-uterine inflammation may 
precede or be the consequence of the mahgnant disease. In the 
latter instance it is simply a reactive inflammation in which 
nature endeavors to bar the progress of the malignant disorder. 
It is important, in investigation of the case, however, to differen- 
tiate between the peri-uterine exudation and the cancerous 
infiltration, as such a diagnosis would influence the operator in 
his treatment of the cancerous uterus. 

Pregnancy is a not infrequent complication of malignant dis- 
ease. Carcinoma in its earliest stages does not contraindicate the 
occurrence of pregnancy. The association of uterine cancer with 
pregnancy and labor presents the gravest danger for two human 
beings. The frequency of the complication may be determined 
by the consideration of the following statistics : Von Winckel, in 
20,000 labors, reported 10, and Stratz 7 in less than 18,000; in 
the Tubingen clinic, in fifteen years, out of 5001 labors there 
were 7 complicated with carcinoma. One cause of the few cases 
of association of pregnancy and carcinoma is the fact that the 
latter exists in the great majority of cases in the later years of 
life after the period of fertility is more or less nearly passed. 
The situation of the disease will have something to do with the 
possibility of pregnancy. In 89 cases of associated pregnancy 
and carcinoma the malignant' disease was found 38 times in the 
cervical canal and 47 times in the portio vaginalis. In 4 cases 
the site was not determined. 

The disease, when complicated by pregnancy, presents no 
symptoms essentially different from those in the uncomplicated 
cases, but, with the necessarily increased congestion of the pelvic 
organs, makes more rapid progress, so the characteristic symp- 
toms — hemorrhage, discharge, and pain — rapidly become aggra- 
vated. Hemorrhage is increased, is more or less copious, and 
is associated with an offensive odor. A profuse, watery, exceed- 
ingly offensive discharge, at times purulent and brownish, is 
constant. The discharge is more abundant and putrid the more 
marked the tissue destruction in the new formation. 

It is of interest to study the effect of carcinoma on pregnancy 
and labor. The disturbances which such complications can 
induce in the course of pregnancy and labor must necessarily 
depend upon the situation and extension of carcinomatous dis- 
ease ; sometimes they are only trifling, but occasionally they may 
mean the death of mother and child. The progressive and severe 
hemorrhage, the profuse leukorrheal discharge, associated with a 
complication of pregnancy, result in general anemia, which pro- 
duces a gradual loss of strength. The existence of the trouble 



GENITAL TUMORS. 775 

renders the development of cancer much more rapid, and conse- 
quently early interference should be considered as indicated. 
The influence upon the labor, when the pregnancy goes to full 
term, depends entirely upon the situation of the disease. The 
accompanying endometritic processes can lead to existence of 
placenta praevia. When the disease is confined to the vaginal 
portion of the cervix, it will not be impossible for labor to be 
spontaneous, but obstructions occur as soon as the portio is circu- 
larly seized in its entire circumference; or, if the cervical canal 
has become strongly infiltrated, the tissue is absolutely unyield- 
ing. Unless prompt measures are resorted to, such an individual 
may suffer from hemorrhage, exhaustion, and fatal termination, 
with the fetus still intra partum. 

Among the complications with labor we can have premature 
rupture of the amniotic bladder and weak labor-pains. If the pains 
remain active, the embryo is forced through, and the process 
results in extensive tearing of the cervix, which may extend to 
the pericervical connective tissue, cause the most extensive 
bruising and crushing of the birth canal, and the cervix may 
even be torn away above the infiltrated ring. Equally significant 
is the infiuence of pregnancy and labor upon the cancer. As 
has been mentioned, it was considered that the existence of 
pregnancy had a beneficial influence on the progress of the cancer 
growth. Von Siebold is reported to have observed the spon- 
taneous recovery of genital cancer from a simultaneous preg- 
nancy. The experience of recent years combats this idea. The 
rapidity of the growth depends upon the character of the disease, 
being much more rapid in the soft and medullary form than 
in the scirrhous variety. The labor can cause the most extensive 
destruction of the parts, and, not only this, but be followed by 
infection of the tissue, which can result in thrombosis, sepsis, 
and pyemia. 

644. Diagnosis. — Hope for radical rehef from cancer will, in 
the majority of cases, be dependent upon its early recognition. 
The investigations of Virchow dismissed the idea of cancer being 
in origin a constitutional disease and demonstrated its purely 
local character. A study of its clinical course, however, in- 
dicates that while the disease is local in character at its origin, 
transmission to the surrounding structures takes place, when the 
disease practically becomes constitutional. It is important, 
therefore, that the practitioner should recognize the gravity of 
the disease at the earliest possible moment. When the condition 
is one of doubt, the attending physician, in the interest of his 
patient, should have the doubt resolved by securing the advice of 
a more experienced man. Only by early recognition and by 
radical treatment before the extension of nests into the para- 



776 GYNECOLOGY. 

metrial tissue can we hope to avoid the fatal termination of this 
disease. It is well recognized that many patients fail to appre- 
ciate the gravity of their symptoms and postpone consulting a 
physician until the favorable period for intervention has passed, 
but it is equally true that many others are subjected to general or 
local treatment or are advised to await the change of life until the 
disease has become hopelessl}^ inoperable. This is frequently 
brought about through aversion of the patient to the gynecologic 
examination, but the physician will be wiser in absolutely de- 
clining to accept the responsibility for the treatment of a patient 
who declines to permit him to employ the necessary means to 
determine her condition. Should he yield to her request, she 
and her friends will subsequently hold him responsible for any 
untoward results. 

The ease with which the diagnosis can be made will depend 
upon the situation of the disease. Following the division already 
given of cancer involving the portio vaginalis, the cervical canal, 
and the'^body of the uterus, prepares one to find different physical 
signs according to its situation. The association of hemorrhage, 
foul discharge, and pain should awaken a profound suspicion 
that should be satisfied only by careful examination. Carcinoma 
of the portio vaginalis is, as a rule, easy to recognize. It is 
accessible to the investigating finger, and is readily exposed to 
vision by the speculum. The most characteristic form is the 
cauliflower growth, which springs by a narrow base from one 
or the other lip, and may fill the vagina. It presents to the 
finger an irregular, nodular mass, which bleeds upon the slightest 
touch, is very friable, and is frequently covered by a greenish 
exudate or slough. The mass may vary from a nodule the size 
of a bean to a growth the size of a fist. Instead of an exuberant 
growth the disease may present an excavated cavity with in- 
durated wall and base and undermined edges. In diseases of the 
cervical canal the external os may present a crater-like opening 
or may appear healthy. In the early stage the disease of the 
cervical canal affords no external or apparent indication of the 
disease. The infiltration involves only the mucous membrane of 
the canal. 

If we follow the rule to secure an accurate examination of 
such cases, it may be necessary to explore the intra -uterine 
cavity. This procedure is best accomplished by the use of 
laminaria tents. These tents should be sterile, and should be 
removed from a saturated solution of iodoform and ether, or, 
better, be soaked in tincture of iodin for a few minutes before 
their insertion. Tissue occupied by carcinomatous infiltrate 
will not readily dilate. The scrapings obtained by the curet will 
often show fragments which are easily broken or crumbled, in 



GENITAL TUMORS. 777 

place of the long, thickened pieces removed in endometritis. The 
curet and, still better, the finger will disclose a roughened, in- 
durated canal, which is characteristic. In a very early stage the 
cervical cancer appears as small, indurated nodules, which later 
become friable. It should be recognized that cancer of the 
vaginal portion does not manifest a disposition to involve the 
cervical cavity early, which knowledge enables us to determine 
that the cervix remains free unless in advanced cases. In doubt- 
ful cases the suspected tissue, either in the form of scrapings or 
an excised piece, should be subjected to microscopic examination. 
The portion of tissue excised should involve both healthy and 
diseased tissue, when the transition from one to the other can 
be better studied. It is objected to the microscopic examination 
that it takes valuable time to prepare the specimens, but Smyly 
suggests the following two methods for rapid examination : First, 
a small piece of firm tissue is selected, dipped in mucilage, placed 
in a freezing microtome, partly frozen sections of which are cut, 
transferred to Miiller's fluid or to a 2 per cent, solution of potassii 
dichromas, and, after from a few minutes to an hour, stained 
and mounted. In the second method a piece of the tissue the 
size of a bean is placed in twenty times the quantity of methylated 
spirit or, preferably, in alcohol for a few hours, then a few hours 
in running water, dipped in mucilage, and sections made after 
freezing. The sections are removed from water to the slide, 
where they are stained with either picrocarmin or rubin and 
orange. These methods are too complicated for the general 
practitioner. 

Spiegelberg has emphasized the closer adhesion of the mucous 
membrane to the underlying tissue in cancer over that which 
exists in inflammation. Our diagnosis must comprise, naturally, 
the recognition of the presence of cancer, and, also, the extent 
of structure involvement and the probability for radical removal. 
Digital examination through the rectum affords accurate in- 
formation as to the extent of the disease in the parametrial tissue 
of the pelvis. Nests or nodules may be found upon the posterior 
surface of the broad ligament, which cause firm fixation by the 
extension of the disease to one or both broad ligaments. We 
should endeavor to distinguish between fixation from previous 
inflammatory trouble and cancerous infiltration. In the latter 
the involved surface is more irregular, presents small, hard 
nodules, and a more distinct limitation, which can be determined 
through the rectum. The latter examination can be more 
effectively accomplished with the patient under an anesthetic. 
A rectal examination should be a matter of routine. Twice I 
have found coexisting rectal cancer in women who otherwise 
would have been favorable cases for uterine extirpation. In 



778 GYNECOLOGY. 

neither of these patients did there seem to be any connection 
between the cancerous growth of the rectum and that of the 
uterus. 

The conditions which can be confused with cancer are : 

Chronic cervical catarrh with laceration. 

Papillary erosion of the cervix. 

Necrosis of fibroid polypus. 

Syphilitic ulceration. 

Partial retention of the products of conception. 

Chorio -epithelioma. 

Sarcoma. 

In chronic cervical catarrh with laceration nature makes an 
effort to repair the injury, the increased weight of the organ 
and its situation lead to eversion of the lips, and the fissures 
are occupied by hard, resistant tissue. The exposure of the 
tender cervical mucous membrane causes inflammatory changes, 
thickening and eversion, obstruction of the ducts of the glands 
of Naboth, and the formation of Nabothian cysts. The surface 
not infrequently is covered with granular tissue, which readily 
bleeds upon the slightest touch; the patient consequently has 
increased bleeding during menstruation, more or less bleeding 
upon exercise, and bleeding following coition. The indurated 
surface with a tendency to bleed, the increased leukorrheal dis- 
charge, the nodular condition produced by the distended glands, 
might readily lead an inexperienced physician to believe that he 
had to deal with cancer. Indeed, many of these cases are so 
close to the border-line as to render it difficult to arrive at a 
certain conclusion. The treatment of the case will frequently 
remove the doubt. Puncture of the cysts and the application of 
caustics cause cicatrization of the surface, and demonstrate that 
it is not malignant. It has been said that Nabothian cysts abso- 
lutely contraindicate the existence of cancer, but cases have been 
observed in which Nabothian cysts are filled with their secretion 
in the immediate vicinity of cancerous degeneration. The ab- 
sence of tissue friable to the touch, the use of the speculum, and, 
when necessary, the examination of an excised piece should 
render the diagnosis of a benign condition positive. 

Papillary erosion of the cervix is sometimes mistaken for a 
carcinomatous ulcer, but the latter is covered with friable tissue 
and bleeds easily. In carcinoma the affected structure is raised 
above the level of the healthy cervix ; in erosion it is depressed. 
The latter has a regular outline, the carcinomatous ulcer an 
irregular, ragged line of demarcation. 

Necrosis of a fibroid polypus is a condition in which the sub- 
jective symptoms are very similar to those of cancer. I recently 
saw a patient, a widow, forty-five years of age, who was suffering 



GENITAL TUMORS. 779 

from a profuse menorrhagia, from a copious foul-smelling dis- 
charge, and had been assured by her physician that she was 
suffering from an inoperable cancer of the uterus. The appear- 
ance of the patient and the odor in the room apparently justified 
the assertion; but a digital examination revealed a large mass 
filling up the vagina, which was firm and resistant, and could be 
turned about from one position to another. The lower surface of 
the mass was somewhat roughened, but its upper surface was 
smooth. The finger, carried well over it, could reach a distinct 
pedicle, which could be traced upward to the uterus ; the cervix 
was thinned, and at no place hard, indurated, or infiltrated ; con- 
sequently, I had no hesitation in assuring her that she could be 
cured. 

In necrosis of a fibroid situated within the vagina the diag- 
nosis is readily made. The firmer resistance, the recognition of 
a pedicle, the absence of any infiltration about the external os, 
and the smooth outline render. its character certain. When the 
growth is situated within the cavity of the uterus, however, it 
may be more difficult. Here a sloughing fibroid causes hemor- 
rhage and a profuse offensive discharge, but the discharge is 
usually thinner, watery in character, and may contain particles 
of the growth. These particles are more in the nature of a 
slough. The uterus is larger in outline, the cavity of the 
organ is frequently open, so that the finger can enter and come 
in contact with the mass which fills the uterus, and, by man- 
ipulation, occasionally fragments of the tissue may be broken 
off and examined under a microscope, or often under macro- 
scopic examination the fibrous structure is recognized, which 
should exclude cancer. Dilatation of the uterus sufficient to 
permit the introduction of the finger discloses the cavity occu- 
pied by a mass which is more or less resistant, not friable, nor 
easily broken down. 

Syphilitic Ulceration. — Syphilitic ulceration should be readily 
distinguished from cancer by recognition of the fact that it does 
not present an excavated surface with indurated base and edges, 
that it is associated with evidence of syphilis in other portions of 
the body, and by the absence of friable tissue upon the ulcerated 
surface. Microscopic examination to fix the diagnosis is gener- 
ally unnecessary. 

Partial Retention of the Products of Conception. — The retained 
tissues may be the embryonic envelope, a portion of the placenta, 
or blood-clots, which, when retained, are subjected' to infection, 
cause an exceedingly foul-smelling and offensive discharge, and 
their presence is a frequent cause of bleeding. The history of 
recent abortion or delivery, the dilated os permitting the intro- 
duction of the finger, and the recognition of the retained products 



780 GYNECOLOGY. 

by exploration determine the condition. The retained products 
scraped away, a smooth surface is left, which is the normal 
uterine wall. The absence of further irritation following cleans- 
ing of the cavity demonstrates its true character. 

Chorio -epithelioma presents a history of a previous abortion 
or labor within a few weeks or months, following which the 
patient suffers from profuse, irregular bleeding, which leads the 
physician to make a curetment in which there is a large amount 
of soft, friable tissue removed. This treatment arrests the hem- 
orrhage for a very brief time, when the conditions recur, and a 
second curetment will disclose the fact that the structure found 
in the first curetment has been reformed. The disease shows a 
marked tendency to early metastasis through the blood-vessels. 
It occurs in patients at an earlier age than carcinoma. The age 
of the patient, the history of previous pregnancy, the severe 
hemorrhages, the rapid development, and the recurrence should 
lead to its diagnosis. The structure can be positively differen- 
tiated from cancer only by the use of the microscope. This re- 
veals that the material is epithelial, but it differs from cancer in 
the absence of the well-marked stroma. In this respect it re- 
sembles sarcoma, but differs from it again in the fact that it is 
composed of epithelial and not of connective-tissue cells. The 
further investigation discloses that this epithelium is the product 
of fetal life and has originated from the covering chorionic villi, 
the syncytial cells. 

Sarcoma causes symptoms similar to those of carcinoma. It 
may be differentiated, however, when it affects the cervix, by 
the polypoid masses projecting from it, sometimes grape-like in 
form. Where the disease involves the body of the uterus, the 
organ is likely to become much larger than is the case in car- 
cinoma. Sarcoma, however, is much more rare than carcinoma. 
The microscope affords the only means for arriving at a positive 
diagnosis. The structure of the sarcoma is homogeneous, and 
consists of connective-tissue cells, either round, spindle, or giant 
cells, without a well-defined stroma; the walls of the blood- 
vessels are invaded and made to appear as mere sluiceways 
throughout the structure. In carcinoma the structure is nest- 
like, with a well-defined stroma, the vessels are situated in the 
stroma, and their coats are not destroyed. 

It is seen that the existence of carcinoma does not preclude 
the possibility of pregnancy. The occurrence of this complica- 
tion renders it important that we should study its course and 
be able to determine its presence. The diagnosis is rendered 
easier by comparison of the hard, firm, infiltrated carcinomatous 
parts with the softer, edematous, healthy tissue of the uterus in 
the pregnant condition. The carcinomatous nodules of the 



GENITAL TUMORS. 781 

vaginal portion of the cervix may be recognized by touch, and 
often as intervening between the finger and the parts of the 
child. In some cases the initial stage of the malignant disease 
may be so slight as to be overlooked, and if the observer is in 
doubt as to the correctness of the diagnosis, a microscopic inves- 
tigation of excised tissue should be employed. More difficult 
even than the recognition of carcinoma is the determination of 
the existence of pregnancy in the earlier months. Pozzi claims 
that it is impossible to diagnose the existence of pregnancy with 
uterine cancer prior to the fourth month. A number of cases 
are recorded in which pregnancy was first recognized during or 
following a total extirpation. It can thus be readily understood 
why pregnancy can be overlooked in the second and third months. 
The earlier recognition of the condition is of extreme value, for 
observations have demonstrated the fact that the increased con- 
gestion which occiu-s in the uterus favors the more rapid develop- 
ment of malignant disease. It was formerly believed that the 
existence of pregnancy during cancer allayed or arrested the 
progress of the latter, to be accelerated subsequent to its ter- 
mination, but careful observation has demonstrated the fallacy 
of this view. On the contrary, the increased nutrition which is 
directed to the uterus by the occurrence of pregnancy favors the 
more rapid development of malignant disease. The recognition 
of the existence of carcinoma, as determined by the microscopic 
investigation of the excised tissue and the simultaneous enlarge- 
ment of the uterus, should cause the complication to be sus- 
pected. 

645. Duration of Cancer. — The duration of life in this disease 
is hard to fix, because we know scarcely anything of its first 
beginning. We have no means of knowing how long a period 
transpires between its origin and the ulceration which produces 
the first symptoms for which the patient is induced to consult 
the physician. The form of cancer is also a determining factor. 
The soft, medullary cancer is rapid in progress and destructive 
in its action. The final catastrophe occurs much sooner than in 
scirrhus. The earlier in life the disease develops, the more rapid, 
as a rule, will be its progress. The period of survival varies, 
according to different authors, between six months and two or 
three years; in squamous-cell cancer, from three to four years; 
in cylinder-cell cancer, from one to two and a half years. A 
somewhat longer period is ascribed to cancer of the body. 
The normal duration of life can be materially altered by thera- 
peutic measures. Cases are seen in which, after operation, 
months or years passed without any indication of relapse. 
This is true not only after radical operation, but the patient 
so improves after the arrest of hemorrhage and discharge by 



782 GYNECOLOGY. 

some palliative measure as almost to cause the patient and 
her friends to doubt the possibility of the disease being of so 
serious a character. 

646. Prognosis. — It is only necessary that one should study 
the clinical course of carcinoma to be convinced that the prog- 
nosis must be bad. The improvement of the prognosis lies, first, 
in the early recognition of the disease ; second, in prompt resort 
to radical operation. The first provision requires its recognition 
even before the characteristic symptoms of the disease are mani- 
fest. A patient in whom the irritative conditions favorable to 
the development of malignant disease exist should be kept under 
observation, and during the period of greatest susceptibility 
should be subjected to a quarterly, at least a semi-annual, exam- 
ination. Causes of special irritation should, as far as possible, 
be removed by appropriate treatment. Second, radical treatment 
should be understood as a procedure which will insure removal 
of the diseased structure within the limits of healthy tissue. 
Always to accomplish this, the operation must necessarily be 
early. The probability of rapid invasion of the deeper structure, 
and of the establishment of secondary nests more or less remote 
from the original site, is less marked in cancer of the body of 
the uterus than in that of the cervix or the vaginal portion. 
Cancer of the uterus in a woman prior to the age of forty years 
is more acute in its progress and much more likely to recur than 
when it occurs in women of more mature years. The prognosis 
of the disease is materially affected by the thoroughness of the 
operative procedure and by the precautions which are exercised 
to prevent reinfection of the new w^ound. Our inability to de- 
termine when and to what extent metastasis has occurred renders 
us unable to fix the prognosis after operation with any degree of 
certainty in the individual case. An apparently hopeful one 
will soon relapse, and one for whom the outlook seems uninviting 
will remain for a long time relapse free, dependent upon obscure 
processes whose rationale we do not fully comprehend. 

The outlook for length of life of the patient suffering from 
cancer of the uterus is affected largely by the occurrence of 
pregnancy as a complication. The prognosis of pregnancy de- 
pends upon the kind and the course of labor and upon the 
general condition of the patient ; above all, upon the extension of 
carcinoma. The more difficult the labor, the poorer the general 
condition of the patient, and the more progressive the disease, 
the more certain will be the unfortunate result and probable 
death. The outlook of the woman suffering from cancer with a 
pregnant uterus is far worse than for the nonpregnant, because 
pregnancy and labor occasion extremely dangerous results. The 
rapid progress of the disease during pregnancy, the severe trauma 



GENITAL TUMORS. 783 

during labor, and the rapid carcinomatous degeneration of the 
tissue affect the result. Chantreuil reported that in sixty preg- 
nant carcinomatous diseased women twenty-five died during or 
shortly after childbirth. Cohnstein, in one hundred and twenty- 
six cases, saw seventy-two die. Hermann had one hundred and 
eighty cases in which seventy-two died. The uterine rupture 
alone had six victims out of Chantreuil' s sixty cases ; eleven out 
of Hermann's one hundred and eighty; nineteen out of one hun- 
dred and twenty-six women, according to Cohnstein, died unde- 
livered — about 8.1 per cent, of all the cases. Under the uniform 
methods of treatment employed of late years, the mortality is 
somewhat decreased. It is now admitted that the treatment of 
complications of pregnancy must be consigned to operative pro- 
cedure, either gynecologic or obstetric. Formerly the treatment 
was limited to artificial abortion and premature labor. But little 
experience, however, was required to demonstrate that such 
measures were ineffective. The course then advised was to pro- 
long the pregnancy as long as possible with a view to secur- 
ing viability for the child, and the obstetric operation became 
the important consideration. Later experience in the various 
methods of treatment has led to the following conclusions : (i) In 
cases in which the cancer has reached a stage where radical 
operation is impracticable every effort should be made to prolong 
the pregnancy until the child becomes viable; (2) where the 
patient, however, is recognized to have the disease in its early 
stages, with a reasonable hope for successful removal, the ovum 
should not for a moment be permitted to prejudice the chances 
for the mother, and radical operation should be undertaken 
without reference to the child. 

647. Treatment. — Our previous study of the anatomic struc- 
ture and progress of development indicates that cancer originally 
consists of a primary nest, from which invasion of the surrounding 
structures occurs. The rational treatment, then, consists in the 
removal of the diseased structure within healthy limits. Upon 
the extent of involvement will depend our ability to remove com- 
pletely the disease, and hence the division into two classes — 
operable and inoperable. The following scheme represents the 
methods of treatment which may be adapted to each class : 



( 



1. Partial extirpation, Vaginal. 

( (a) Vaginal. 

2. Total extirpation, ] (b) Abdominal. 

(A) Operable. \ [ (c) Sacral. 



/ _ f (a) Cureting. 



3. Palliative operations, < (b) Caustics. 

( (c) Cautery. 

(B) Inoperable, j 4- Injections, {^^\ Ckan^n^^^'''' 

i 5. Anodynes. 



784 GYNECOLOGY. 

648. (A) Operable. — Partial Vaginal Operations. — As car- 
cinoma uteri largely preponderates in the cervix, it is quite con- 
ceivable that the early operations were directed to the extirpation 
of that section of the organ involved. Von Grafenberg, as early 
as 1600, reported that the uterus had been normally extirpated 
in a number of cases, but it is most probable that the majority 
of these were amputations of the cervix, particularly as the 
subsequent continuance of menstruation is noted in several 
women, and, indeed, the birth of children. In the early cases 
hemorrhage was controlled by styptics, and many of the patients 
succimibed to hemorrhage and sepsis. 

Partial extirpation has remained, until the last fifteen years, 
the principal, if not the exclusive, operative method of combating 
carcinoma. It consisted in the removal of the diseased parts with 
knife or scissors, and the control of hemorrhage with the cautery 
or strong fluid caustic. The difficulty in controlling hemorrhage 
led to the employment of the chain or wire 6craseur, by which 
the diseased tissue is crushed off. A marked improvement was 
the employment of the galvanocautery loop — the galvanic loops 
placed upon the cervix above the margin of the disease, tightened, 
and the cervix amputated. This procedure was extensively 
practised by C. Braun and Byrne, with extraordinary results. 
The latter made the procedure still more effective by substituting 
the galvanic knife for the loop. 

Neither the employment of the ecraseur nor the use of the 
loop can be considered as an ideal surgical procedure, for, with 
the first, injury of the neighboring organs can not always be 
avoided, and, with the second, it is not always possible so to 
place the loop that amputation of the vaginal portion of the 
cervix results with certainty in healthy tissue. A more progres- 
sive method was instituted by returning to amputation with 
the knife and union of the wound surfaces by sutures. The 
procedure was introduced by Hegar, who made a funnel-shaped 
incision. Schroder perfected supravaginal amputation of the 
cervix, a method capable of meeting all the requirements of the 
present partial uterine extirpation per vaginam. 

Amputation of the Cervix with the Galvanocautery Loop. — The 
preparation for vaginal operation (Section 182) is made, exercis- 
ing care to penetrate and disinfect the neck. The cervix is ex- 
posed with specula or retractors, seized with hook forceps which 
dip into the healthy tissue, and drawn upon, while the platinum 
loop is placed as high as possible, coming immediately under the 
transverse folds which indicate the position of the bladder, and 
is so tightened that it cuts into the tissue. As the excision pro- 
gresses the vagina is protected from heat by wooden plates and 
syringed several times with water in order to thus cool the 



GENITAL TUMORS. 785 

tissues and preserve them from burning. The wire must be kept 
at a red heat in order that the surfaces shall be well scorched. 
The wire should be tightened slowly until the cervix is cut 
through. When the operation is accomplished with due delibera- 
tion, there is no subsequent tendency to bleeding. The higher 
the wire is placed upon the cervix, the more probable it is that 
Douglas' pouch will be opened. The occurrence of such an acci- 
dent, however, requires no more consideration than to pack the 
cavity with iodoform gauze. By the employment of the galvano- 
cautery knife Byrne improved the operation. He cut around the 
vagina, separated it from the cervix, and was enabled to remove 
the latter at a higher level. 

Hegar's Operation. — The funnel-shaped amputation of the 
cervix described by Hegar is accomplished as follows: The 
cervix is fixed by double tenacula and drawn downward. A 
knife is introduced as far away from the limits of the disease 
as safety for the bladder and ureters will permit, and is carried 
about the cervix, held at such an angle as to cut out a cone- 
shaped mass, the apex of which would be high in the cervical 
canal. The hemorrhage is controlled by sutures and tamponade. 
Baker operated in a similar manner, but controlled the hemor- 
rhage with the cautery, while Van de Warker cauterized the 
surface with zinc chlorid. 

Schroder's operation is a supravaginal amputation, of which 
the following is a description: The cancerous portion is exposed 
by Simon's retractors. With a sharp curet all removable tissue 
is scraped away from the new formation until the curet reaches 
firm tissue, when the entire bleeding surface is scorched with 
a hot iron, the vagina being protected from the heat and fre- 
quently irrigated as the operation proceeds. The cervix is 
seized with a vulsellum and drawn downward as far as pos- 
sible. An incision — if possible, one centimeter from the dis- 
ease margin — is carried about the cervix; with the index-finger 
or a gauze pledget the bladder is bluntly separated from the 
anterior uterine wall. The bladder and ureters are thus shoved 
upward, when the anterior wall of the neck can be removed at 
a high level. In this operation Douglas' space is frequently 
opened, but the cervix is retained in connection with the lateral 
parametrium. The cervix is pulled to one side, while with a 
Deschamps needle a ligature is passed as far away from the 
cervix as possible, tied firmly, and the tissue cut between the 
neck and the ligature. If the tissue is thick, a number of liga- 
tures may be applied, one above another, and when the op- 
posite side is likewise treated, the cervix is cut away. When 
necessary, all the cervix below the internal os can be removed. 
If Douglas' pouch is opened, the circumstance may be^^made 

50 



786 GYNECOLOGY. 

useful in closing the parametrium, as the needle can be passed 
upon the finger, introduced through the opening. The cervix 
is then amputated at the level of the internal os. The section 
is made through the anterior vaginal wall to the cavity, and, 
before proceeding further, the anterior vaginal wall is stitched 
to the anterior cervical wall with from two to four sutures. 
The amputation is completed by cutting through the posterior 
wall, when the surfaces are sutured as in the anterior. A num- 
ber of sutures are now applied to the lateral portions of the 
wound to insure closure. The sutures should be carefully 
placed in the lateral angles in order to secure the uterine arteries. 
When they are ineffectually secured, hemorrhage may be free 
and threaten a fatal result. The patient can arise in from 
ten to twelve days and be discharged after from eighteen to 
twenty days. 

The high amputation of the cervix has had many advocates, 
who champion it in preference to extirpation as being safer 
and less prone to subsequent relapse. The employment of 
the galvanocautery knife may produce a beneficial influence 
in the destruction of cancer nests which would be overlooked 
by the scalpel. An objection to the operation is that the cer- 
vical opening may contract and become closed, causing subse- 
quent distress, and necessitate further operative procedure 
to relieve the dysmenorrhea or hematometra. Cases of preg- 
nancy have been reported, but the difficulty in labor was so 
great, because of the scar tissue, that operative delivery was 
required and the patients died. Similar experience has been 
observed in the Hegar operation, owing to the difficulty in 
introducing the sutures. All these disadvantages are avoided 
by the Schroder operation. 

The investigations of Seelig have demonstrated that in- 
fection has been carried through the lymphatics to the cervix, 
and even to the body, of the uterus. Such an occurrence would 
render anything less than extirpation of the entire organ of 
no service, and no positive means exist for determining w^hen it 
has taken place. An additional reason for preferring the entire 
extirpation is that the cicatricial tissue is always irritable, and 
is a source of danger in a woman predisposed to undergo malig- 
nant change. The removal of the uterus and ovaries brings 
about a lessened congestion of the pelvic tissues, and will cer- 
tainly leave the patient free from subsequent periodic engorge- 
ment of the pelvic structures. The cases suitable for the partial 
operation are infrequent. 

649. Total Extirpation of the Uterus. — Isolated examples 
of total extirpation of the uterus have been mentioned as hav- 
ing occurred at various times during the eighteenth century, 



GENITAL TUMORS. 787 

but it remained for Czerny and Freund to formulate procedures 
which have led to the more complete satisfactory methods as 
represented in the operations of vaginal and abdominal hyster- 
ectomy of the present day. 

Total extirpation may be undertaken in one of two stages 
of development: first, when no evidence of involvement of 
the parametrium exists, when the object is to eradicate the 
disease by ablation of the organ and the surrounding portions of 
the vagina and parametrium, or to operate within healthy tissue ; 
second, when there is some involvement of the parametrium 
with fixation of the uterus. The latter operation is not cura- 
tive, but may ameliorate symptoms. 

In performing the radical operation two 'purposes should be 
kept in mind: (i) To keep beyond the confines of the disease 
by operating in healthy tissue; (2) to protect the patient from 
any possibility of reinfection. 

1. The recognition of the processes of development and 
the extension of cancer make it absolutely uncertain in any 
individual case that this purpose has been accomplished. The 
operator is absolutely unable to determine, prior to operation, 
that circulatory or irritative extension has not involved the 
parametrium beyond the safe limits of operation. In some 
this transmission may occur early in the disease, in others 
late, so that in a woman with but slight involvement and no 
demonstrable evidence of extension a favorable prognosis is 
usually given. However, not infrequently in these cases the 
physician is horrified to find a recurrence after a very brief 
period, while in others the entire vaginal cervix may be destroyed, 
and he operates radically, though only with a hope of amelio- 
ration, but the patient remains free from recurrence for years 
or even permanently. 

2. The possibility of reinfection or of the transplantation 
of portions of cancerous structure upon a healthy w^ound and 
the reproduction of the disease from it is questioned. Such 
a view would seem a reasonable explanation for the redevelop- 
ment of cancer in a wound where microscopic investigation 
indicated that the operator was well beyond the confines of 
the disease. The opponent of infection, however, justly in- 
stances the possibility of metastatic nests in the parametrium, 
discoverable only by the microscope, from which the recur- 
rence has followed. Such statements for the vicinity of the 
wound are difficult to combat, but if, in a single case, the dis- 
ease can be transplanted to the abdominal wound in an abdom- 
inal hysterectomy, it should be considered proof that such 
reinfection may occur, for that region would be entirely out of 
the usual route for metastatic extension. Such an infection 



788 GYNECOLOGY. 

came under my observation in the practice of one of my col- 
leagues, in a young unmarried but not childless woman. Within 
two months of an abdominal hysterectomy nodular masses 
were observed in the abdominal wound, which subsequently 
progressed. In two cases of my own experience transplantation 
has occurred. In both of these patients there were extensive 
involvement and obstruction of the cervix by a squamous- 
cell carcinoma. In the first patient a sinus remained in the 
abdominal wall following a stitch abscess, in which prolifera- 
tion of the epithelium occurred. This resulted in a spreading 
sore, involving the tissue circumjacent to the abdominal in- 
cision. As this patient had pelvic involvement as well, the 
possibility of continuous involvement must, of course, be con- 
sidered, although I was apparently able to excise the infected 
abdominal tissue without opening the peritoneal cavity. The 
second patient, an unmarried woman, unden^^ent operation 
June 19, 1900. The entire cervix was involved in a cauliflower 
growth to such a degree that her attendant, a surgeon of con- 
siderable experience, questioned the advisability of operation. 
She was exceedingly anemic and broken dowm by repeated 
hemorrhages. She was continually nauseated and vomited 
everything taken for five days subsequent to the operation. At 
the close of a week it was found that all the sutures had cut 
through, the wound was gaping, and the intestine protruding. 
The wound had been closed with silkworm-gut sutures for all the 
tissues above the peritoneum, and continuous chromic catgut for 
the latter and the aponeurosis. The intestines were packed back 
with gauze, and a week later the wound was closed with through- 
and-through silkworm-gut sutures under cocain anesthesia. 
The patient left the sanatorium five weeks subsequent to the 
performance of her operation, with good union in the abdominal 
wound. Much to the surprise of her attendant and myself 
she enjoyed, barring a very small ventral hernia, excellent 
health for over two and one-half years. She began to have dis- 
comfort and swelling in the line of the wound, and a lump could 
be felt which was thought to be a strangulated and inflamed pro- 
jection of the omentum. However, the mass gradually increased 
in size and became painful, and, therefore, a provisional diagnosis 
of recurrent malignant disease was made. This was excised 
June 18, 1903, three years from the date of her previous opera- 
tion. Now, three years after the second removal, this patient 
is in the enjoyment of excellent health and exhibits no indica- 
tion of further recurrence.* A mass of infiltrate as large as a 

* Since the above was written I have been consulted by this patient and 
examination reveals a malignant neoplasm involving the vesicovaginal septum. 



GENITAL TUMORS. 



789 



hen's egg occupied the center of the cicatrix. The omentum 
and a portion of the iletmi were adherent and had to be sepa- 
rated with scissors ; a portion of the intestine was also involved 
in an annular band of tissue, for which three inches were 
excised and unifed by an end-to-end anastomosis. Careful 
examination failed to reveal any other evidence of the dis- 
ease, the pelvis disclosed no sign of any infiltrate or glandular 
enlargement, although careful observation was made. It may 





Fig- 525. — Formation of Flap to Cover Diseased Surface Preliminary to 

Operation. 



seem that the two and one-half years which intervened before 
the development of this growth would argue against trans- 
plantation, but is it any more difficult to consider transplanted 
cells as lying latent and inactive in this area than those which 
have been transmitted to the parametrium to develop within 
the five years, a period which all authorities admit should 
transpire before a case can be pronounced as cured? 



790 GYNECOLOGY. 

Whether we accept or reject the theory of infection, the 
precautions taken to prevent it are only such as will be of ser- 
vice in rendering the parts sterile and in preventing infection 
from pathogenic germs, w^hich every one will admit are present. 

Preliminary Treatment. — In every extirpation of the organ, 
whether by the vagina or the abdomen, in addition to the prepa- 
ration indicated in Section 182, precautions should be exercised 
to remove all diseased and disintegrated tissue. The surface 
should be gone over with a sharp curet, all loose and ragged 
edges trimmed with scissors, and the entire surface thoroughly 
scorched with the thermocautery. Sutures should then be 
placed to close up the diseased surface. If the entire vaginal 
cervix is more or less involved, incisions should be made upon 
each side which will permit flaps to be turned down and sutured 
over the diseased structures. The vagina should be continu- 
ously irrigated during the process of closing off the diseased 
surface and this procedure followed by careful sponging with a 
solution of sublimate in alcohol (i : 500). 

650. Vaginal Hysterectomy. — Many isolated cases of ex- 
tirpation of the uterus per vaginam are found in the literature 
of the last century, notably those of Langenbeck and Sauter- 
Recamier. Czerny, on August 12, 1873, revived the opera- 
tion. The operation has also been variously modified. The 
following method should be pursued: 

1. After the preliminary preparation directed (Sec. 182), 
place the patient in the lithotomy position, expose the uterus 
with an Edebohls speculum and lateral retractors, make traction 
upon the cervix with double tenaculum and vulsellum or a silk 
loop passed through it, draw it down as near to the vulvar orifice 
as possible, and close the cervix by sutures, making flaps where 
necessary to close in the diseased tissue. Sterilize the hands 
and the instruments so far used. 

2. Separate the cervix with scissors, knife, or thermocautery 
(preferably the latter) from the vaginal wall by an ovoid incision, 
extending it as far away from the diseased tissue as safety for 
the bladder and ureters will permit. This can be carried higher 
on the posterior surface without the fear of injuring the rectum. 
The thermocautery knife has the advantage that it decreases 
hemorrhage, destroys additional infected tissue, and prevents 
immediate union, thus favoring better drainage. 

3. Push back the bladder from the anterior wall of the 
uterus and from the broad ligaments. Where desirable to re- 
move a large portion of the parametrium, expose each ureter 
and place upon it a traction ligature, as suggested by Bovee, 
when the uterine artery can be traced out and ligated near 
its origin. 



GENITAL TUMORS. 791 

4. The fundus of the uterus is turned down through the 
anterior vaginal fornix, the broad hgament seized upon the 
left side, crushed by the angiotribe, ligated in the groove, and 
the uterus separated. Repeat this process upon the right. 
Seize any bleeding vessels with hemostatic forceps and ligate 
them. 

5. Unite the peritoneal surfaces with a continuous catgut 
suture, taking the precaution to secure at either angle the stump 
of the broad ligament. Cleanse the cavity and loosely pack 
the vagina with iodoform gauze. 

All sutures should be of catgut, as silk is likely to become 
infected and produce a discharge and maintain a sinus until 
it comes away, w^hich may require months, unless previously 
removed. Such a patient will be in constant apprehension 
that the disease is returning. The disposition of the ovaries 
and tubes will depend upon their situation and the extent of 
the disease. If they are easily displaced downward, they 
should be removed; if high up, requiring considerable manip- 
ulation to displace them, they should be permitted to remain, 
as they cause no trouble. With the completion of the opera- 
tion the wound should be carefully inspected for any bleed- 
ing vessels, as it is not impossible that a ligature may slip from 
the stump and a fatal hemorrhage result. Bleeding points should 
be picked up and secured with separate ligatures. 

The treatment of the wound will depend on the condition 
of the patient. Thus, if the patient is very much debilitated 
and it is undesirable to keep her long under the influence of 
an anesthetic, the wound may be packed between the stumps 
with iodoform gauze, carrying the latter sufficiently high to 
prevent the intestine from coming in contact with the raw 
surfaces. The gauze packing is lightly placed in the vagina 
and the vulva covered with a pad. This packing, w^hen the 
blood control has been complete, may be permitted to remain 
for from four days to a week. Upon its removal the cavity 
is irrigated with a i : 2000 formalin solution, and may be lightly 
repacked, although the packing should not be carried so high 
as the first portion. The anterior and posterior walls of the 
vagina are thus permitted to fall together and become adherent. 
If there is no tendency to displacement of the viscera down- 
ward and the belly of the patient is not distended, the gauze 
need not be replaced, and the vagina may be kept clean by 
irrigation. In relaxed vagina, or when the condition of the 
patient will permit of more time for the operation, the ends of 
the broad ligaments should be united and the stumps drawn 
well into the vagina; the sides of the vagina are united to each 
stump by a deeply passed suture, which, when tied, holds up 



792 GYNECOLOGY. 

the vagina and avoids its subsequent relaxation for want of 
support. The patient should be confined to bed for two weeks ; 
frequently cases are permitted to rise earlier than this, but the 
long rest in bed is no disadvantage. The pelvic floor is firmer 
and is less likely subsequently to prolapse. 

Various modifications of the operation of vaginal hysterec- 
tomy have been suggested. Three years after Czerny introduced 
it, Sanger was able to collect thirteen dift'erent methods of operat- 
ing, and with each year subsequent other modifications have been 
suggested. Mikulicz was the first to use the curet. Billroth and 
Olshausen added scorching the surface with the thermocautery; 
others, in addition, cauterized with carbolic acid or chlorid of 
zinc, or used iodoform, liquor ferri chloridi, alcoholic bromin solu- 
tion, and absolute alcohol. Tauffer made his preliminary prep- 
arations several days before the operation, and Leopold advo- 
cated disinfection as the first step. Schauta began the operation 
with the thermocautery. Bottini, Wecchi, and Calderini am- 
putated with the galvanocautery loop, and followed with ex- 
tirpation. When cancer is situated high in the cavity of the 
uterus, antiseptic syringing is practised, the cavity packed 
with iodoform gauze, and the os closed over it with sutures 
or with clamp forceps. In order to limit the discharge of secre- 
tion in carcinoma of the body, Schauta introduced a tupelo 
tent into the cervix. This tent was somewhat constricted in 
the middle from perforation, and a thread was introduced, 
the ends of which were armed with needles. These needles 
perforated the cervical canal anteriorly and posteriorly, and 
the ends of the suture were tied over the end of the tent. The 
swelling of the tent acted as a plug to the cervical canal. Mac- 
kenrodt introduced the formation of flaps from the anterior 
and posterior vaginal surfaces, which we have described. Lan- 
dau advocated an ovoid incision, the posterior surfaces some- 
what higher than the front, as such an incision gave greater ac- 
cessibility to the operation field. Doyen lengthens the circular 
incision by one right and left, in order to create a still larger 
opening, and especially to be able to separate about the bladder 
and the ureters more securely. Fritsch incised both sides of 
the vagina; the base of the broad ligament is cut and tied, so 
that in this manner the uterus is easily movable and readily 
drawn down before the cervix is separated from the anterior 
and posterior union. Schatz opens into Douglas' space; then 
the uterus is completely freed from its lateral union, and, finally, 
the bladder is separated from the cervix. The ureters have 
been injured in this method of operating. Billroth separates 
by degrees the broad ligament, ligates the individual vessels, 
and fastens the broad ligament in a properly prepared clamp 



GENITAL TUMORS. 793 

forceps. Schroder drew the uterus through the opening of 
Douglas' space into the vagina. This procedure is not always 
performed with ease. Fritsch rotated the uterus through the 
anterior peritoneal opening. Olshausen operated with the 
uterus continuall}^^ in situ, and endeavored to separate it first 
on that side which showed the least invasion by cancer. Corradi 
and P. Mtiller rendered removal of the uterus easier by dividing 
it into two portions by a sagittal section, and then removing 
each half singly. Kelly divides it into four or more. This 
procedure, without question, renders the removal of the uterus 
more easy, but if we believe in the reinfection of the wound, 
it greatly increases the danger. The ligation of the broad 
ligaments has also given great variety of procedure. Some 
ligate small sections; others ligate in mass. Olshausen, in the 
beginning, attempted to surroimd the broad ligament with a 
single ligature, but the stump would shrink and the vessel re- 
tract from the ligature and considerable hemorrhage result. 
Liebmann attempted to ligate the parametrium in such a manner 
that the ligature is knotted on the vaginal mucous membrane in 
order to limit its slipping. The superior part of the broad 
ligament, with the spermatic vessels, repeatedly slips from 
the ligature and requires supplementary ligation, which is 
accomplished with great difficulty. Veit fastens the superior 
part of the stump with hook forceps and ties the ligament be- 
hind them. 

With regard to the removal of the ovaries there has been 
considerable discussion. Czerny, in his first case, removed 
the appendages supplementary to the removal of the uterus. 
Schroder, Olshausen, and others leave them when no indication 
of disease is found. Von Teuffel and Kaltenbach urge their 
removal; the latter emphasized the possibility of infection 
of the peritoneum by leaving inflammatory diseased portions 
of the tube. The retention of the appendages in carcinoma 
of the uterine neck is not found to favor the appearance of 
relapse. The course of the lymph-channels arising from the 
cervix has no relation to the appendages of the uterus. They 
should always be removed whenever pathologic alterations 
are recognizable. After Reich, in several cases of carcinoma 
of the body, had demonstrated cancerous disease of the ovary, 
the removal of the appendages was advocated in all cases 
in this form of uterine cancer. Formerly surgeons employed 
irrigation freely with strong antiseptics during the early part 
of the operation. To-day, the majority of gynecologists, after 
radical disinfection of the field of the operation, proceed with 
sterilized instruments without irrigation. Irrigation should 
be employed only when necessary to cleanse the field, and it is 



794 GYNECOLOGY. 

better then to use nothing stronger than normal salt solution 
or a I per cent, saline solution. 

The vaginal operation will be especially difficult if the canal 
is narrow and rigid or the uterus very large. Under such cir- 
cumstances the majority of operators have incised the vaginal 
wall or the paravaginal tissue, by which procedure the lumen 
of the vagina is considerably increased. Von Winckel, in one 
case with enormous narrowing of the vagina and a large uterus, 
split the entire rectum and rectovaginal septum up to the vaginal 
vault. The large vaginorectal wound was sutured with silk, 
and recovered by primary intention. Diihrssen made a deep 
vaginal incision, which penetrated from the vaginal vault and 
completely opened the ischiorectal cavity and the entire vagina. 
Section on the right side penetrated the vagina, and also the 
rectum, to the depth of six or seven centimeters. By this 
incision not only the vaginal tube, but also the surrounding 
muscular structure, the levator ani, and the constrictor cunei 
are separated. The direction of the incision is in the middle 
line, between the tuber ischii and the anal opening. By such 
an incision the entire field of the operation is incidentally in- 
creased, and the resistance of the soft parts of the pelvic cavity 
is removed. The hemorrhage from the vagino-intestinal in- 
cision is either controlled by ligature or through pressure of 
retractors. After the removal of the uterus the wound is closed 
by sutures. After such an incision relapses have occurred 
in the scar tissue, which are evidently infection relapses. Schu- 
chardt creates a still larger accessibility to the field of opera- 
tion by opening more widely the ischiorectal cavity. He makes 
two accessory incisions. One splits the entire lateral vaginal 
wall, from below to the neck; on the other side a long vaginal 
incision from behind progresses to the sacrum and encircles 
the rectum, bow-like, in an incidental sagittal section. The 
long incision is made upon the side in which the parametrium 
is strongly involved, and extends to the outside of the convex 
bow at the side of the anus. The extirpation of the uterus 
in these operations differs from the usual vaginal extirpation 
only in that the parametrium has been opened up so that some 
cancerous nodules can be removed therefrom without exposure 
of the ureters. The vagina is closed from above downward 
by knotted suture. 

While it cannot be denied that these extensive vaginal in- 
cisions permit greater freedom in the manipulation of the uterus, 
the ease with which it can be reached from above would seem to 
contraindicate such a method of procedure, especially in view 
of the increased danger of reinfection of parametric tissue that 
must be associated with so extensive a dissection. To facili- 



GENITAL TUMORS. 795 

tate the removal of larger portions of the parametrium with 
safety, Pawlik, Kelly, and Clark advocated the previous intro- 
duction of catheters into the ureters to establish their position 
more definitely and permit, with safety, the extensive removal of 
large portions of t'he parametrium. The dissection and guard- 
ing of the ureters, as Bovee suggests, are preferable and safer, for 
one case of catheterization has been reported in which the cathe- 
ter was broken off and the patient died. Its employment inflicts 
more or less trauma and, therefore, predisposes to infection. 
Mackenrodt, in total extirpation, cuts about the vagina some 
distance from the portio and prepares anterior and posterior flaps, 
which are drawn over the portio and sutured so that the diseased 
tissue is completely covered. He splits the anterior vaginal 
vault by a median incision from the urethral swelling to the cir- 
cular incision. The accessibility of the operation field is still 
further increased by a deep vagino-intestinal incision. The 
bladder is dissected from the cervix, and especially from the broad 
ligaments, and therewith the ureters are separated some dis- 
tance ; and, finally, the uterus, with as large a portion as possible 
of the parametrium, is extirpated. The peritoneal wound is 
closed after the contraction of the stump, the vagino-intestinal 
incision narrowed by suture, and the vagina, with the supra- 
vaginal wound, packed with iodoform gauze. Later, Macken- 
rodt performed an operation in which the extirpation of the 
uterus and of the greater part of the vagina was accomplished 
with the hot iron. He believes that a larger extent of the 
vagina must be removed than is customary, because we do not 
know that a latent contact infection of the vagina does not 
already exist. He performs the operation as follows: 

With cutting instruments, Paquelin cautery, or galvano- 
cautery the entire vagina, or at least the upper half of it, is 
separated; a vaginorectal incision is made which extends to 
the portio and lays open the operation field; then the vagina 
is seized with forceps and separated downward by hot iron. 
If the upper part of the vagina only is removed, we begin with 
a circular incision in the middle of the vagina. After extirpa- 
tion of the vagina the portio is secured with forceps and Douglas' 
cavity is opened with a hot iron. The bladder and the broad 
ligaments are separated from the cervix by a properly con- 
structed shovel forceps, drawn as far as possible to the outside, 
and separated by the cautery. After the separation of the 
base of the broad ligament of both sides spurting vessels are 
seized with Koeberle forceps, which are placed in the higher 
part of the broad ligament, separated by the cautery, and the 
stump scorched. The now very movable uterus is easily in- 
verted. The upper parts of the broad ligaments are fastened 



796 GYNECOLOGY. 

with Richelot's clamps and a ligature is placed on each side, 
after which the separation of the stump results. After the 
removal of the uterus the rectovaginal incision is closed by- 
sutures, when, in spite of the scorching, primary union is usually- 
obtained. The perineum is not sutured. The burned cavity- 
is filled with iodoform gauze. Elevation of temperature follows. 
Of ten cases subjected to this operation, two suffered from 
sepsis. 

Byrne has removed the entire uterus by the galvanocautery, 
but used the knife instead of the loop. Winter and Frommel 
combat the possibility of the danger of contact infection of 
the vagina being great enough to justify such a procedure. 
Czerny, Franck, and others have pursued the method suggested 
by Langenbeck of separation of the uterus from its peritoneal 
envelop, and the several resulting tears in the peritoneal cover- 
ing were united by sutures. This operation is sometimes very 
easily done, but in others is extremely difficult. Richelot and 
Pean advocate the use of clamps instead of the ligature. The 
preliminary steps of the operation are performed similarly 
to those already described. After opening the peritoneum in 
front of and behind the uterus, the organ is held by the broad 
ligaments, through which enter the uterine and ovarian arteries. 
Clamp forceps are applied at each side of the cervix, upon about 
one-half of the broad ligament, and the structure is cut between 
the cervix and the clamp. The uterus is drawn down, if pre- 
ferred, and the fundus is brought forward and through the 
anterior fornix; clamp forceps are applied from above upon 
the remaining portion of the broad ligament. The section 
between the clamp and the uterus frees that organ, which can 
be removed. The clamps are then held apart, the surfaces 
are separated by retractors, and careful inspection is made to 
determine that all bleeding vessels are controlled. Any spurting 
vessels should be secured with smaller clamp forceps or the 
arteries should be ligated. The clamps are held apart and iodo- 
form gauze is carried into the vaginal canal betw^een them 
to the point at which the peritoneum has been separated, and 
is loosely packed between the clamps. The gauze should be 
carried over the end of the clamps, so that the coils of intestine 
shall not impinge against them and become injured. The 
operation has the advantage that it can be performed very 
expeditiously, and requires much less time than the application 
of the ligature. It has the disadvantage that the tissue within 
the grasp of the clamp undergoes sloughing, causes a foul dis- 
charge, an offensive odor, and sloughing tissue which endangers 
the infection of the peritoneal cavity. The convalescence of 
such patients is usually attended with considerable elevation 
of temperature. 



GENITAL TUMORS. 797 

Tuffier reports twenty-seven cases of vaginal hysterectomy 
without the use of forceps or Hgatures. The uterus was bisected, 
one-half drawn out of the vulva, the finger passed behind the 
upper part of the broad ligament, and the included tissue grasped 
between the blades of a powerful clamp, the angiotribe, which 
is tightly screwed. The tissues are thus crushed and the artery 
is occluded. After the crushing of the tissues the ligament 
is cut through and the upper part of the broad ligament crushed 
in a similar manner. It is very important that the handle 
should be secured as tight as possible and the blades kept in 
the axis of the vagina. In none of the cases reported had any 
accident occurred during the operation, and absence of hemor- 
rhage was particularly noted. This procedure is also advocated 
quite strongly by Dr. Newman, of Chicago. The angiotribe, 
however, cannot always be relied upon for the control of hemor- 
rhage, and in some cases it tears the vessel, making its control 
by ligature difficult. Dr. Downes, of this city, has greatly 
improved upon this method by the use of electro-hemostasis. 
The late Dr. Joseph Eastman placed the patient in the Sims posi- 
tion, stretched the anus to allow greater readiness of access to the 
pelvic cavity, retracted the perineum with a Sims speculum, and 
made an incision about the uterus, which opened the Douglas 
culdesac posteriorly and between the bladder and uterus ante- 
riorly. He then passed a curved staff over the broad liga- 
ment, by which a ligature was carried and the broad ligament 
secured en masse, then over it was passed a pair of interlocking 
forceps by which the broad ligament was constricted, preliminary 
to its being severed, after which the ligament could be ligated in 
sections or the clamp permitted to remain. The other broad Hga- 
ment was treated in a similar manner. The advantage he claimed 
for this procedure was greater security and control of hemor- 
rhage, and that the vagina was held at a lower level and its 
prolapse prevented. The position of the patient, with the pre- 
liminary dilatation of the anus, gives greater freedom of access 
to the uterus. 

651. Accidents of Vaginal Total Extirpation. — The most 
frequent injury is that of the bladder, which can take place 
in various ways. Thus, it may occur in the blunt separation 
from the anterior cervical wall. The danger of this becomes 
the greater the more closely the new formation has approached 
the bladder. If it has passed over on to the external layer 
of the bladder-wall, we may very readily puncture the bladder 
in the most careful separation. When the bladder is infiltrated, 
the preferable plan is to cut out the diseased tissue and close 
the opening by sutures. Injury of the bladder is recognized, 
however, most frequently for the first time at a longer or shorter 



798 GYNECOLOGY. 

period after the operation, when a part of the urine is lost through 
the vagina. Either a small bladder injury has been overlooked, 
or, what is probably more frequent, the bladder has not been 
sufficiently separated from the ligament, and in placing the 
ligatures upon the parametrium a portion of it is fastened in 
the ligature, so that a slough of the affected bladder- wall occurs. 
A spontaneous closure not infrequently results from the scar 
retraction. When it has not closed, the repair of the fistula 
must be undertaken by operation. Kaltenbach claims that 
injury of the urinary apparatus occurs in about lo per cent, 
of all cases; this, for the last few years, should be top high. 
An injury of one or both ttreters is occasionally observed. The 
injury can be avoided if the bladder and ureters are w^ell pushed 
back. It does not require the previously mentioned sounding 
of the ureters to avoid ureteric injuries. One should exclude 
cases from operation in which the parametrium and the sur- 
roundings of the ureter are infiltrated with carcinoma. In such 
cases the shoving back of the ureter is exceedingly difficult, and 
not infrequently is associated with injury. The most serious 
injury of the ureter consists in the application of a ligature 
upon it or upon the tissue about it so that it is laterally com- 
pressed. Ligation of both ureters is, without question, fatal, 
and the ligation of one manifests considerable injury. Schatz 
does not believe the ligation of one ureter necessarily unfavor- 
able, as the other kidney performs increased duty. He also 
believes that in one case after ligation of the ureter the canal 
again became penetrable a few days later. A number of operators 
have had to remove the corresponding kidney as a result of 
the ligation of the ureter. Zweifel, in double-sided ureteric 
ligation forty-eight hours after the operation, loosened the 
ligattires on the one side, and the strongly swollen ureter was 
made accessible again to the bladder; but as urine retention 
continued six days after the operation, the ligature on the 
other side was removed and the restoration of the ureters at- 
tained. 

Injuries of the rectum are more unlikely to occur. They 
take place in especially unfavorable cases where adhesions exist 
between the uterus and the rectum. Frommel reports a case in 
which, in an attempt to open Douglas' space, the adherent rec- 
tum was injured, and, in spite of the most carefully introduced 
sutures, he lost the patient from septic peritonitis. In rare cases 
communication between an intestinal loop and the vagina, with 
involuntary fecal discharge, has occurred, most generally from 
relapse in the operation scar, in which the carcinoma extends 
upon an adherent loop of intestine. Numbers of cases are 
reported in which ileus has resulted from adhesions in the open 



GENITAL TUMORS. 799 

peritoneal wound. It was my tinfortunate experience to have 
this occur nine years after the original operation. In symptoms 
of ileus the intestinal loop should be separated from the vagina 
after reopening the wound. In old cases the condition is best 
treated through an abdominal incision. If this fails, an arti- 
ficial anus should be made or the affected loop of intestine should 
be resected. 

652. Abdominal Hysterectomy. — The first systematic opera- 
tion for the removal of a uterus for malignant disease through 
an abdominal incision was performed by W. A. Freund, on the 
30th of January, 1878. The operation has undergone a number 
of modifications since his introduction of it. After preHminary 
preparation (Sections 173 to 183) the operation is performed as 
follows : 

1. The patient is placed in the lithotomy position, the friable 
tissue is removed from the cervix with the finger and spoon 
curet, all loose and ragged edges are trimmed with the scissors, 
the surfaces seared with the thermocautery, and the lips sutured 
to close in all infected tissue. Where this cannot otherwise be 
accomplished, flaps should be dissected. Before proceeding 
further, the hands and instruments should be resterilized. 

2. The patient is placed in the Trendelenburg posture and 
an incision made in the median line from three centimeters 
above the symphysis to a short distance below the umbilicus, 
through which the intestines are pushed toward the diaphragm 
and walled off by gauze. 

3. The uterus is secured by a double tenaculum and vulsellum 
forceps or sutures which have been passed through the fundus, 
drawn up, and each broad ligament clamped, one blade of the 
clamp being passed through the ligament in such a way as to 
include the round ligament. 

4. Cut the broad ligaments internal to the clamps,- secure 
bleeding from the uterine side by hemostatic forceps, join the 
extremities of the broad ligament incision by one through the 
anterior peritoneum above the bladder, and strip it and the 
bladder away from the cervix and broad ligament. 

5. Find and secure the uterine artery upon each side with 
hemostatic forceps and cut between them and the uterus. 

6. Tilt the uterus to one side and open into the vagina, 
making sure the opening is well below the infected area. Through 
this opening the cervix can be followed around and severed from 
the vagina. 

7. The clamped vessels are ligated — the uterine by simple 
chromic catgut ligature, the ovarian en masse, after being crushed 
with the angiotribe. 

8. The surface is carefully inspected for bleeding vessels and 



800 GYNECOLOGY. 

infected glands, the peritoneal folds are stitched over the vagina 
with a continuous chromic catgut suture, inverting all ligated 
stumps into the vagina. 

9. Remove all gauze pads, cleanse the pelvis, and close the 
abdominal wound, cleanse and apply dressing. Where the con- 
ditions make it desirable, after stripping back the anterior peri- 
toneum and bladder the broad ligament can be spread out, the 
uterine artery traced outward and ligated near its source, the 
ureters raised, held to one side by traction ligatures, and a 
much larger portion of the parametrium removed. 

The vaginal opening can be packed from above with iodoform 
gauze, an end of which is carried into the vagina, while the 
portion above covers the injured surfaces and prevents the con- 
tact of intestines. This gauze should be permitted to remain 
from four to six days, until the peritoneal surfaces have been 
closed over the vagina, and have made it an extraperitoneal 
surface. Some surgeons prefer to suture the peritoneal flaps, 
and loosely pack the wound from the vagina with iodoform gauze. 
The gauze, however, can be used more effectively from above, 
sewing the peritoneal surfaces over it. It thus forms an effec- 
tive tampon and can some days later be removed through the 
vagina. 

In Freund's first procedure the broad ligaments were ligated 
external to the appendages, a second ligature was placed on the 
portion of the broad ligament which included the round ligament, 
and a third secured the base of the broad ligament by being 
introduced from the vagina through a trocar needle which 
Freund devised for the purpose. The last ligature was tied upon 
the base of the ligament as firmly as possible. In this way 
three ligatures were inserted, one under another. The other 
broad ligament was secured in the same manner. The perito- 
neum above the bladder fundus was cut transversely upon the 
anterior uterine wall. A similar section was made upon the pos- 
terior wall, somewhat lower, and these wound margins were 
united with a silk loop after the removal of the uterus. The 
uterus was separated by knife or scissors. Hemorrhage from 
small vaginal arteries was controlled by ligation. All the liga- 
tures were carried into the vagina, and by traction the stump 
was drawn down. This dragging made the peritoneum of the 
bladder approach that of the posterior wall of the pouch of 
Douglas. These two walls could be united by continuous catgut 
suture. A most careful toilet of the peritoneum was accom- 
plished, the eventrated intestines were returned, and the belly 
wound was closed with sutures. The sutures that were pushed 
into the vagina could be removed by traction at the end of 



GENITAL TUMORS. 801 

three weeks. The greatest danger of the operation was infection 
of the peritoneal cavity. 

This operation has undergone various modifications. Cred6 
proposed to resect a part of the anterior pelvic wall several days 
before the operation, but found no imitators. A. Martin made a 
moon-shaped abdominal incision from the one anterior superior 
spine to the other, by which he hoped to be better able to keep 
the intestines in the abdominal cavity. He has not continued 
the procedure. The separation of the bladder from the uterus 
prior to the introduction of the base sutures has been a great 
improvement, decreasing the danger of injury of the bladder 
and of ligation of the ureters. Kuhn raised the uterus by 
means of the colpeurynter in the vagina, and made it more acces- 
sible. Eastman accomplished the same thing by a grooved staff 
through the posterior vaginal fornix. Bardenheuer advocates 
leaving open the peritoneal Avound for drainage, but his results 
were not such as to make the plan acceptable. 

Modifications of the operation are, first, to make an incision 
through the vagina around the cervix ; pack the cavity with iodo- 
form gauze and complete the operation from above. Another is: 
separate the front and back, open into the vagina, and complete 
the operation by the application of clamps to the broad ligament. 
Veit operated by ligating and cutting the broad ligaments as far 
as the vault of the vagina; then he completed the operation 
through the vagina. Gubarroff, of Moscow, advocates the ab- 
dominal procedure, because of the impossibility of the removal 
of lymph-glands and the tissue at the base of the broad ligament 
in vaginal total extirpation. 

In marked involvement of the cervix Rumpf proceeded by 
the following plan : He ligated the broad ligament above, opened 
up the parame trial connective tissue, and proceeded to expose 
each ureter in its entire course from the psoas muscle, to the 
bladder; thereby the uterine arteries were severed and ligated, 
and the parametrial tissue could be removed bluntly nearly to 
the uterus without incidental bleeding. Subsequently, the ante- 
rior leaflet of the broad ligament was cut through, the peritoneum 
over the surface of the bladder divided transversely, and the 
latter bluntly separated from the cervix. The parametrial tissue 
beneath the ureter could be still further removed. • The vagina 
was separated by means of a Paquelin cautery, after the removal 
of the uterus, was filled with iodoform gauze, and the peritoneum 
was closed over the rest of the broad ligament. Rumpf reports a 
case operated upon in this manner which remained free from 
relapse for over two years. Clark and Kelly effected the same 
purpose by introduction of fine bougies into the ureters to render 
them perceptible. 

51 : 



802 GYNECOLOGY. 

Ries advocates the removal of the lymphatic glands on 
account of their being the source from which redevelopment 
occurs. He operates in the following manner: 

1 . Through the vagina he amputates the portio vaginalis and 
tampons with iodoform gauze. 

2 . Through the abdominal incision from the symphysis to the 
umbilicus he ligates the ovarian artery in the infundibulopelvic 
ligament near the pelvic wall, and splits the peritoneum over 
the common ihac, exposes the vessel by blunt and sharp dissec- 
tion until the bifurcation is exposed, when the ureter is separated 
as far as the bladder. 

3 . The broad ligament is ligated toward the pelvis in sections 
and the part toward the uterus is secured with clamps. The 
bladder is separated bluntly from the surrounding broad ligament 
and the uterine artery tied peripherally. 

4. The collected fat tissue with the glands is removed from 
between the large vessels, the external and internal iliac. 

5. The vagina is opened, the uterus removed, and the vaginal 
canal filled with iodoform gauze, while the peritoneal flaps are 
united with continuous silk suture and the belly cavity com- 
pletely closed. 

When infection is so great as to require so extensive a separa- 
tion, the danger from sepsis and from relapse of the disease is 
so marked as to render the operation of questionable value. 
Werder, of Pittsburg, in order to lessen the danger of wound 
reinfection, advocated an abdominal hysterectomy in which, 
after ligation of the broad ligaments, the bladder is pushed off 
not only from the anterior surface of the uterus, but from the an- 
terior portion of the vagina for one-third to one -half its length. 
The tissues are also separated from the vagina posteriorly and 
laterally, the abdominal wound is closed by a previously intro- 
duced suture or hooked forceps ; the uterus is then drawn through 
the vaginal [outlet and the remaining portion of the operation 
completed by the vulva, which saves the wound from contact 
with the infected portion. 

In order to control hemorrhage in an extensive dissection of 
the pelvic structures, Polk advocated ligation of the anterior 
trunk of the internal iliac artery. (Fig. 526.) The distribution 
of vessels from these trunks is, however, somewhat irregular, the 
vessel itself is short, and the structures supplied by the posterior 
trunk are so bountifully nourished by anastomotic vessels that 
I have tied one or both the internal iliac vessels, which permitted 
a most extensive dissection free from bleeding. In all of these 
cases the involvement of structures was so extensive that the 
operation was of doubtful utility. The first patient survived 
the operation and returned home, but soon perished from a re- 



GENITAL TUMORS 



803 



lapse ; the second case developed tetanus at the end of ten days 
after the operation, from Avhich she died. 

Schroder, after ligation of the infundibulopelvic ligaments 
and the portion of the broad ligaments containing the uterine 
arteries, amputated the fundus at about the level of the internal 
OS. After bleeding vessels had been secured and the stump dis- 
sected out, the vaginal surfaces were united, over which the peri- 
toneal flaps were sutured. The operation is objectionable because 
of the danger of reinfection. ]\Iackenrodt urges not only the 




H.iS. 
Fig. 526. — Ligation of the Anterior Trunk of the Internal IHac, 



removal of the glands of the pelvis, but also an extensive re- 
moval of the parametric tissue, since in the latter metastatic 
nests were most frequently found, which were the chief cause 
of recurrence. In order to accomplish this most effectively, he 
advocates the following procedure : 

I. A large crescentic abdominal incision from one iliac spine 
to the symphysis and upward to the opposite is made, through 
which insertions of the recti muscles are divided without opening 
the peritoneum, and the abdominal muscles are separated from 
the pehdc attachments. 



804 GYNECOLOGY. 

2. The peritoneum is pushed off to its reflection over the 
anterior wall of the bladder, when it is cut through and pushed 
behind the uterus. 

3. The uterus is drawn out and the ovarian arteries ligated 
in the usual manner. The peritoneum is then sutured behind 
the uterus from the right side of the pelvis across to the left, 
covering the sigmoid flexure, which permits the subsequent steps 
to be extraperitoneal. 

4. The pelvic peritoneum is dissected up as high as the iliac 
vessels, where the glands are found and removed with fat and 
connective tissue. During this stage the ureters are carefully- 
protected. 

5. The bladder and rectum are separated, the entire vagina 
freed . 

6. The broad ligaments and paravaginal tissues dissected out, 
the vagina clamped and divided with cautery below the clamps. 

7. The space between the bladder and the abdominal wall is 
drained through the lower angle of the external wound. The 
divided recti are united by silver wire sutures and the abdominal 
wound closed. Considerable suppuration is usually expected 
between the bladder and the rectum. In none of the cases thus 
treated has the absence of recurrence been sufficiently long to 
make the performance of so extensive an operation seem justi- 
fiable. 

Wertheim, Kronig, Kundrat, and von Rosthorn are very 
earnest in their advocacy of the removal of the parametrium and 
lymph-glands in all cases of carcinoma. While I would agree 
with them as to the importance in getting well beyond the dis- 
ease, in the removal of a large portion of the parametrium and of 
the vagina, my experience leads me to believe that the attempt 
to remove the glands is of little avail, as it is impossible for the 
most skilful surgeon to remove all the glands, and the investi- 
gations of Schauta seem to indicate that the inaccessible lumbar 
glands are frequently infected before those in close relation with 
the uterus. Fortunately, the involvement of glands does not 
always indicate that these structures will be the cause of recur- 
rence when the original source of the disease has been removed. 
In the great majority of the cases coming under my observation 
recurrence has followed in the vagina and cicatrix rather than in 
the pelvic glands. When the increased mortality incident to 
the prolonged operation, the tedious convalescence, the aggra- 
vated suffering from ureteral and vesical complications are con- 
sidered, it becomes a serious question whether anything is gained 
by the extensive and more thorough procedure. Wertheim, the 
apostle of this procedure, had an immediate mortality of 1 2 in the 
first 30 cases, 5 in the second, and 3 in the third series of thirty. 



GENITAL TUMORS. 805 

Even the latter, which equals lo per cent., is a much larger mor- 
tality than men of equal experience usually have in ordinary 
hysterectomy. 

653. Comparative Advantages of the Two Proceedings. — The 
principal danger of the abdominal procedure arises from septic 
infection. The investigations of Menge and others have demon- 
strated the presence of pyogenic germs in the discharges of 
uterine cancer. The much longer duration of the operation, the 
increased exposure to infection, and the lessened powers of resist- 
ance favor its development. In the vaginal procedure the peri- 
toneum is less exposed to infection, and the operation can proceed 
without any, or with scarcely any, soiling of the peritoneal cavity. 
In our present methods of procedure the operation is more expe- 
ditious ; with the separation of the bladder from the cervix and 
the broad ligament the uterine artery can be ligated without 
danger to the ureter. 

The claim for the abdominal procedure, that it permits the 
extirpation of the lymphatic glands, is of but little significance 
when it is remembered that the glands are rarely involved until 
very late in the disease ; and when the disease has extended to the 
lymphatic glands of the pelvis, the operation is but little better 
than a mutilation, for it will scarcely have any influence upon 
the subsequent progress of the disease. 

Notwithstanding the vaginal operation can be done much 
more expeditiously and with less danger to the patient, with less 
discomfort during the convalescence, it can not be denied that 
in cancer of the uterus, where the disease is confined to that 
organ, the abdominal operation should be preferred. This prefer- 
ence is granted it not because it permits us to extirpate the 
lymphatic glands, — for I believe that no operator is sufficiently 
skilled to make sure that all the lymphatic glands are removed, 
and even if they were, the extensive lymphatic system would 
still afford opportunities for the retention of infection, — ^but 
because it enables the operator with greater safety to remove 
the parametrial tissue. The large number of cases in which 
vaginal hysterectomy has resulted favorably, the fact that where 
recurrence takes place it is in the cicatrix, in the vaginal wall, 
or in the parametric tissue, lead me to believe that the assertion 
regarding the infrequency or lateness of lymphatic gland infection 
is correct, and that where the disease has resulted in the involve- 
ment of the glands,, no operation affords much hope of cure. 
In cases in which it is evident that the disease has extended 
outside the uterus and the operation is done for its palliative 
effect, removing only the infected tissue, the vaginal operation 
may be preferred, where the vagina is large and roomy and 
the uterus not unduly large. . 



806 GYNECOLOGY. 

A narrow contracted vagina, a large or fixed uterus, extensive 
involvement and destruction of the cervical walls, which afford 
no firm tissue to be seized, and more or less fixation of the uterus 
from inflammatory lesions, render the vaginal procedure very 
difficult. Complications of the diseased uterus with abdominal 
growths, such as myoma, ovarian tumors, and extra -uterine 
pregnancy, should be attacked through the abdomen. When we 
come to the duration of after-results, the advantage seems to 
favor the abdominal procedure. 

Injuries of the ureters occur less frequently by the abdominal 
route, but the operator, in all cases of extensive involvement of 
the parametrium, should ascertain the position of the ureter by 
following it down from above before blindly applying a ligature. 
Through neglect of this precaution I have twice ligated a ureter. 
If the ureter is unavoidably or accidentally injured, an attempt 
may be made to unite it by suture, as was done by von TaufTer 
and Westermark, or the ureter may be implanted in the bladder. 

In extensive parametrial involvement, where the infiltrate 
surrounds the uterus, I have in several cases purposely cut 
through one or both ureters, dissected out the involved structure to 
the pelvic wall, and reinserted the ureter into the bladder at a higher 
level. In all of these patients the ureter was distended to the 
size of a finger as a result of compression from the infiltrate. All 
recovered from the operation, but four succumbed some months 
later to recurrence of the disease. Kiistner, when unable to ac- 
complish a vesical transplantation, formed a vesicovaginal fistula, 
followed later by a colpocleisis in preference to a nephrectomy. 

654. The Sacral Method. — Kraske, in 1885, introduced an 
operative procedure, under the title of the sacral method, for 
the purpose of extirpating the upper part of the rectum for 
carcinoma. It consisted in resecting the rectum after the re- 
moval of the coccyx and a portion of the sacrum. Hochenegg, 
in 1888, after a series of brilliant successes, adapted the opera- 
tion to the treatment of some of the disorders of the female 
sexual organs, and the following year reported the application 
of the method to the removal of the uterus. The operation was 
performed as follows: The patient was placed in the Sims posi- 
tion, with the pelvis slightly elevated, an incision was made 
from two to three centimeters above the right sacro-iliac synchon- 
drosis to within one centimeter of the left side of the anus. 
After cutting through the skin and fascia, the under part of 
the sacrum and the entire coccyx were exposed. Now follows 
the bone operation. If the coccyx is large and broad, its re- 
moval is sufficient; otherwise a portion of the left sacral wing 
is also resected. If a part of the sacrum is to be removed, we 
cut through the sacrosciatic ligaments, and with a rongeur 



GENITAL TUMORS. 



807 



cut away the left side of the lower two segments of the sacrum. 
The prevertebral fascia is split the entire length of the wound; 
the now free-lying rectum is bluntly separated on the left side 
and displaced to the right. Later experience demonstrated 
the advisability of opening upon that side of the rectum on 
which the para'metrium was most infiltrated. The rectum 
is shoved aside, and Douglas' space opened by a transverse 
incision, which is recognized as the hardest part of the opera- 




Fig, 527. — Skin Incision for Sacral Resection. 



tion. One or two fingers are introduced into the opening, 
the uterus and its appendages are explored, and the practic- 
ability of their removal is determined. 

In removal of the uterus it is seized and drawn through the 
incision of Douglas' space into a position of strong retroflexion. 
The broad ligaments upon both sides are cut between double 
ligatures; when the uterus becomes so movable that it can 
be further drawn down, its anterior surface is inspected. The 



GYNECOLOGY. 



peritoneum above the vesico-uterine reflexion is cut trans- 
versely, and, together with the bladder, pushed downward. 
The uterine arteries are generally ligated under the eye, and 
the ureters easily pushed aside, although they have been in- 
jured. After the separation of the lateral appendages the organ 
remains in union only with the vagina. A transverse incision 
through the peritoneum in front of the uterus is made, which 
is separated and sewed to the peritoneum of the anterior wall 



4HHP ' 


i., ''■■^Bar 


"~^K^ - 


i 





Fig. 528. — Sacrum Resected; Rectum Exposed. 



of the rectum. The vagina is closed in two stages. Iodoform 
gauze is packed about the remaining portion of the wound 
and brought out at the center of the posterior wound, both 
ends of which have been closed. This operation was extended 
by Herzfeld, who found that, in the majority of cases, only 
the removal of the coccyx was required. He penetrated the 
right side of the rectum, for the reason that the vagina is situated 
more to the right, is more accessible, and there is less inter- 



GENITAL TUMORS. 



809. 



ference with the rectum. The transverse opening is made 
in Douglas' space, the right and left broad ligaments are tied 
and cut, after which follows a complete closure of the perito- 
neum before further extirpation. There is no possibility of 
soiling the peritoneal cavity by contact with cancer. The 
rectal peritoneal 'surface is sewed to that of the bladder, and 
the stumps are fastened in the wound laterally, making them 




f- 



Fig. 529. — Rectum Ptished Aside; Uterus Exposed. 



extraperitoneal. Hegar cut transversely in the anterior uterine 
wall above the bladder fundus, and shoved back the bladder 
and ureters. The remaining removal of the uterus is similar 
to that described in Hochenegg's and Herzfeld's operation. 
Schede protests earnestly against sacrificing the sacrum. In 
a large series of operations he never found it necessary to re- 
move enough of the sacrum to involve the lower sacral foramen 
and its nerve. He designates the removal of the lower two 



•810 GYNECOLOGY. 

sacral nerves a crime, as the destruction of these nerves para- 
lyzes the detrusor vesica uterini and causes a very severe in- 
flammation of the bladder, which increases the distress and 
peril of the patient. Zuckerkandl introduced a still more 
conservative method, in which there was no bone resection. 
Skin section was from the left side of the tuberosity of the 
ilium until midway between the end of the coccyx and the 
anus. At the sacral margin it formed a bow bent hard to the 
right. The gluteus maximus muscle, the sacro-iliac and sacro- 
sciatic ligaments, the musculus coccygeus, and part of the 
levator ani muscle were cut through at the margin of the sacrum 
and coccyx. The rectum is set free and the operation pro- 
ceeded with as previously described. 

Wolffler places the skin section to the right of the sacrum, 
over the somewhat narrowed part at the union of the coccyx 
and sacrum; the section forms an easy curve, with its concavity 
to the right, and ends near the rectum, in the neighborhood 
of the vulvar commissure. The gluteus maximus and the 
levator ani are cut near the rectum, and the deeper structures 
become accessible. Zuckerkandl designated his and Wolfller's 
methods as parasacral section. These operations are more 
bloody, because the sacral, the median, and the inferior hemor- 
rhoidal arteries and the pudendal artery and vein are in the 
range of the incision. Hegar made an osteoplastic resection 
of the sacrum and coccyx. A V-like incision, with the arms 
beginning one centimeter beneath each inferior posterior iliac 
spine, converged to the point of the coccyx. After separation 
of the soft parts and bands near the sacral margin the rectum 
was bluntly separated from the anterior sacral surface, a chain- 
saw was introduced between the third and fourth sacral open- 
ings, the sacrum cut transversely through to the posterior 
periosteum, which was retained, and the sacral part turned 
up. After the operation this flap w^as returned to place and 
secured by sutures. Consolidation usually took place in a 
very short time. In two cases necrosis resulted, and the flap 
had to be removed. After the operation the skin wound was 
closed, with the exception of a small drainage opening, and 
the advantage of the procedure is that the anatomic relations 
are exhibited as before. This osteoplastic resection of the 
sacrum is applicable to the removal of carcinomatous uteri as 
well as retro-uterine tumors. 

Kocher and Heinecke recommend the splitting of the sacrum 
in the middle and the separation of the sides from one another. 
Levy and Schlange, in opposition to Hegar, turned the flap 
toward the anus, while Rydygier made the incision in the soft 
parts on one side, and, after transverse incision, turned the 



GENITAL TUMORS. 811 

sacrum toward the other side. Borelius changed this method 
in the removal of a carcinomatous uterus as follows : He began 
with the skin section in the middle line, about two centimeters 
above the sacrococcygeal articulation; then, somewhat to the 
left, approached the point of the coccyx forward, through the 
rectosciatic fossa, three to four centimeters from the anal aper- 
ture ; from this point he progressed forward, and again approached 
the middle line until led to the posterior commissure. After 
laying free the left border of the coccyx, the sacrococcygeal 
angle is cut through. The skin section, in its entire length, 
is sufficiently deepened, and the coccyx, together with the anal 
portion, is held to the right; after separation of the rectum we 
can proceed from the posterior vaginal wall to the extirpation 
of the sexual organs. After the operation the coccyx is replaced 
and fixed with periosteal sutures. 

Various modifications of Hochenegg's procedure for the 
extirpation of the uterus have been introduced; by proceed- 
ing, as Herzfeld suggested, to the right of the rectum, Douglas' 
space will not be missed. In the search for the space — made 
incidentally easy by having an assistant introduce the finger 
into the rectum to indicate the plica trans versalis recti, as the 
cup of Douglas' space always lies at the height of this fold — we 
only need to make the incision to enter the space. The difficulty 
in finding Douglas' space has occasioned the majority of operators 
to renounce the primary opening in the peritoneal cavity en- 
tirely, and to proceed to the extirpation of the uterus by the 
opening from the vagina. 

Incidentally an easy way of accomplishing the uterine 
extirpation would be to follow the proceeding of Czerny, who 
from the vagina cuts about the portio in the same manner and 
separates the structures as in the vaginal method. After com- 
pletion of the operation most operators fill out a somewhat 
fist-sized wound with iodoform gauze and treat it as an open 
wound, with the exception that the wound in the skin is partly 
closed, leaving an opening in the center, through which the 
iodoform gauze is carried out ; also, in the osteoplastic resection 
we can not well renounce the use of this drain, and iodoform 
gauze is placed on each side. Steinthal brought the gauze 
out through the vagina, and thus closed the entire posterior 
wound. Zweifel, Schauta, and Wertheim have operated in 
similar manner with favorable results. One objection to this 
operation is the long convalescence, requiring fully six weeks 
for the patient to recover, after which time necrosis of the 
bone may cause fistulous openings, which may continue for 
a much longer period. The osteoplastic resection seems to 
shorten the convalescence. The complete suturing of the 



812 



GYNECOLOGY. 



sacral wound, with drainage through the vagina, is the most 
satisfactory procedure. It can be claimed for the procedure 
that the entire operation can be accomplished more readily 
under the eye, and ligation of the uterine arteries is accomplished 
separately, and not by mass ligature. Injuries of the ureters 
are also easy to avoid. Such injuries, however, do occur. 

The operation may be found advisable in cases in which 




Fig, 530. — Patient from Whom Uterus, Ovaries, Posterior Wall of Vagina, 

Perineum, and Five Inches of the Rectum Have Been Removed. 

A. Artificial anus. B. Anterior wall of vagina. C. Vulva. 



there is reason to suppose that the ureter is embedded in in- 
filtration. In one case Schede resected a piece of the bladder 
three centimeters long, together with a long piece of the ureter. 
Von Winckel objects to the operation on the ground that he 
could not see the ureters. Hochenegg reported ninety-eight, 
with eighteen fatal cases — eight times sepsis or pelvic phlegmon. 
The loss of blood is much greater than in the vaginal opera- 



GENITAL TUMORS. 813 

tion. In the course of the after-treatment Hfe may be endan- 
gered by bursting of the peritoneal wound. Hochenegg points 
out that, by reason of the sacral method, a large series of cases 
are reported of carcinomata of the bladder; the ureter and 
parametrium have, become more or less involved and in- 
creased the technical difficulties that .complicate the opera- 
tion. I have removed the uterus, ovaries, and tubes by sacral 
resection in one case without injuring the rectum, and in two 
cases with resection of the rectum. All these cases recovered. 
In one of the latter the operation consisted in the removal 
of five inches of the rectum, the uterus, ovaries, and tubes, 
the posterior wall of the vagina, and the perineum. The rectum 
was stitched to the skin over the sacrum and to the anterior 
wall of the vagina. This operation was performed for epithe- 
lioma involving the rectum, extending to the perineal margin 
around the anus, and in the parametrial tissue behind the uterus. 
The patient had previously undergone a Maydl colostomy. 
After the recovery of the posterior wound an incision was made 
around the artificial anus and the two ends of the bowel were 
raised and reunited, after which all fecal discharges took place 
through the sacral anus. Thirteen months after the opera- 
tion the patient returned to her home in Ireland, since which 
time no knowledge has been obtained of her progress. 

655. The Perineal Method. — Zuckerkandl, in the year 1889, 
presented a method for extirpation of the uterus by an opening 
between the vagina and rectum. With the patient in the lith- 
otomy position, the intestine was raised toward the sacrum with 
a ,/ \ -shaped flap incision, whose nearly seven centimeters 
long transverse portion lies in the half oval line in front of the 
rectum, and whose angles upon each side extend to the ischial 
tuberosities. After separation of the skin and superficial fascia, 
and separation of the skin-flaps from the under layer, the pro- 
jecting bundle of the external sphincter, which penetrates the 
labial commissure, is separated and the lower part of the vagina 
loosened from the rectum. The remaining part of the septum 
is bluntly dissected until Douglas' fold is reached, when the 
vagina is opened transversely, the uterus drawn out from be- 
hind, and its extirpation occurs as readily as in the sacral method. 
The peritoneum is closed, and, after removal of the uterus, 
the ligament stumps can be buried in the peritoneal cavity or 
placed by sutures extraperitoneally, as in the vaginal method. 
Frommel seems to be the only one who has found this operation 
practicable. He holds it advantageous to cut about the vagina, 
as in the vaginal method, push back the bladder, pack the 
vagina with iodoform gauze, and then perform the perineal 
operation. The operation is quite bloody, as the numerous 



814 GYNECOLOGY. 

venous plexuses between the vagina and rectum are opened. 
The operation seems an unnecessary interference with the 
pelvic floor, as the same increased room will be secured by 
enlarging the vagina and the danger from infection must neces- 
sarily be very greatly increased. 

656. The Mortality of Abdominal and Vaginal Operations.— 
The operative mortality must necessarily be governed by the per- 
centage of carcinomatous cases submitted to operation. The 
surgeon, who finds but 20 per cent, of his cases operable, accepts 
less risk than the one who operates 50 or 60 per cent. Thus, 
in a Berlin clinic, out of 402 carcinoma cases, but 83 were found 
operable. Wertheim, in his first series, operated but 29 per cent., 
while in the last, 51 per cent, were operable. The mortality may 
also be influenced by the character of the operation. The radical 
procedure, which aims to remove the parametrial tissue and the 
infected glands, must necessarily be attended with a large mor- 
tality. Wertheim had from 10 to 40 per cent, respectively in 
his last and first series. The mortality may be fixed at 6 to 10 
per cent, for abdominal hysterectomy where ordinary care is 
exercised to remove the adjacent parametrium without reference 
to the glands, and from 3 to 5 per cent, for the vaginal pro- 
cedure. 

657. Duration of Recovery. — In the earlier operative work 
it was considered that if a patient survived the operation two 
or three years without recurrence, she might be pronounced 
cured, but further experience has demonstrated that recurrence 
may take place up to the fifth year. After this lapse of time 
the probability of permanent recovery is very great. There are 
occasional cases in w^hich recurrence after partial operation has 
been discovered as late as six, seven, or eight years. It would 
be a question in these cases, however, whether it might not be 
considered a condition similar to that which would take place 
in a woman whose susceptibility to malignant degeneration was 
great, and that the irritation produced in scar tissue would 
favor such development and should be considered a primary, 
rather than a secondary, condition. Frommel, in his investiga- 
tions, has never seen recurrence follow after four years. In 
one hundred and eighty-eight cases of cancer of the neck and 
twenty-six cases of cancer of the body reported by Fritsch, he 
saw sixty-five free of recurrence at the end of one year, or 58.5 
per cent, of the cases in the neck and 69.2 per cent, of those in 
the body. At the end of two years Olshausen saw one hundred 
and forty-one, or 44.7 per cent., of the neck, and sixteen, or 
81.2 per cent., of the body, free from recurrence; at the end of 
three years he reported one hundred and twelve, or 37.5 per 
cent., of the neck, and thirteen, or 69.2 per cent., of the body. 



GENITAL TUMORS. 815 

At the end of four years he found free from recurrence of cancer 
of the neck eighty-eight, or 29.5 per cent.; of the body, eleven, 
or 63,6 per cent. From this collection it is rendered evident 
that in the first and second years after operation the great ma- 
jority of recurrences appear, and then more and more the num- 
ber falls off. The duration of life following an operation largely 
depends upon the stage of advancement of the disease. Leopold 
is quoted by Williams as having recorded a recurrence of 23.7 
per cent, in early cases as contrasted with 66 per cent, in a more 
advanced stage. 

The final results of individual operators, however, are so 
very different that it is impossible in general to draw valuable 
conclusions from them. Thus, Kaltenbach, with his brilliant 
primary operative results, evidently extends the indications 
for the operation quite far, and subjects all cases to it in which 
it seems technically possible. It is quite readily understood 
that in such a number of cases there must be a few in whom 
the new formation has advanced proportionately far, and that 
relapse is not surprising. Leopold, on the other hand, drew 
the indications very narrowly. The investigation of statistics 
demonstrates that the vaginal operation has given excellent 
primary results, but, on the other hand, it shows that, of all 
the radical operations to which patients are submitted, after 
a year in one-half recurrence has followed, and that it recurs 
in the second year in a still considerable percentage. The 
gravity of the disease can be still further appreciated when 
we realize that only a small percentage of the cases which come 
under the observation of the gynecologist are in a condition 
to permit of radical operation. 

658. Recurrence. — Those cases subjected to radical opera- 
tion when the parametrium is without doubt extensively in- 
filtrated are not only immediately followed by recurrence of 
cancer, but a fatal termination is also very rapid. Tannen 
has proved that the duration of life in such recurrence of the 
disease is briefer than it would have been had the disease been 
let alone, for duration of life of eight and nine months for 
patients in whom the disease thus recurs is less than would 
be secured by such palliative treatment as partial resection or 
energetic cauterization of the diseased area. Sanger and Thorn 
have shown that by the latter the duration of life is lengthened. 
Surgeons, from their experience in mammary cancer, are in- 
clined to combat these views, but statistics do not support 
them. As contraindications, then, against total extirpation 
are to be considered great enlargement of the uterus and ex- 
tensive adhesions, especially with intestine. Those uteri should 
be excluded from vaginal operation which can not be removed 



816 GYNECOLOGY. 

through the vagina without morcellation. To this class belong 
those carcinomata which are complicated with myomata. Preg- 
nant and puerperal uteri are proportionately easy to remove 
by the vagina, in spite of their enlargement, as has been demon- 
strated by Olshausen, Hofmeier, and others, and the compara- 
tive narrowing of the vagina observed in the nullipara and in 
old women exhibits no contraindications to the vaginal opera- 
tion. 

The primary operations are so satisfactory that we could 
scarcely wish them otherwise. Olshausen 's one hundred total 
extirpations with but one death, when some of the patients 
were already pyemic, are positively brilliant results. Winter 
describes three forms of recurrence: (i) Local or recurrence 
in the wound — a return of the cancer in its primary kind within 
the compass of the field of operation; (2) lymph-gland re- 
currence, and return of the tumor in any lymph-gland of the 
body; (3) metastatic recurrence. Dissemination by the blood- 
vessels leads to the development of the tumor in the more in- 
ternal organs. The first is produced either by portions of carcino- 
matous growth which have been overlooked in the operation 
or fragments that have been broken off and found lodgment 
in the folds of the wound. These correspond more or less to 
the neighborhood of the previous operation, which demon- 
strates the correctness of Thiersch's view, confirmed by Heiden- 
hain's investigation on mammary cancer, that the carcinoma 
frequently extended itself far over the lateral or immediate 
limits in small sprigs, and that, after the removal of the new 
formation, the mass is seen to be separated by healthy tissue 
from visible sprigs or microscopic cancer-nests that may be 
the source from which the cancer redevelops. 

Our study of the progress of the disease has already illus- 
trated the extension of carcinoma of the vaginal cervix in the 
vault and parametrial connective tissue. Mackenrodt and 
Leopold, in their anatomic investigations of extirpated parts 
of the parametrium, have demonstrated fine, microscopically 
perceptible sprigs situated in remote parts of the parametrium, 
and it is quite possible that such fine sprigs may be found out- 
side of • the incision as well. It is, consequently, difficult to 
be certain whether wound relapse occurs from sprigs of cancer 
growth in the parametrium or from small masses which have 
been broken off from the diseased tissue and been implanted 
upon the new wound. Most generally the patient gains in 
body-weight and improves in appearance after the operation, 
but individual cases will be found to exhibit pain in the depth 
of the pelvis at an early period, which radiates from the lower 
extremities, and frequently becomes very distressing. In 



GENITAL TUMORS. 817 

its further course there is edematous swelHng of the lower ex- 
tremities, not rarely venous thrombosis; in other cases, bleed- 
ing and discharge, which cause the patients to return for in- 
vestigation. 

The diagnosis^ of carcinoma recurrence is mostly fixed with- 
out difficulty if we make a combined investigation from the 
rectum, with the thumb in the vagina, by which the penetrated 
parametrium can be fixed between the finger-tips. Hemor- 
rhage may sometimes take place in granulations which are 
formed about the ligatures, especially if silk has been used. 
When the appendages have been left, a mass may be felt in 
the vagina that has a soft sensation. The cause of bleeding 
upon an exact examination is recognized as the fimbriated end 
of the tube. The absence of infiltration and the impossibility 
of separating the small tumor masses from a polypus of the 
vagina contraindicate carcinoma. In doubtful cases the tissues 
should be examined with the microscope. Another form of 
recurrence is that of which Winter speaks as infection-relapse, 
in which portions of carcinoma are broken off, come in contact 
with healthy tissue, there lodge, and develop the original dis- 
ease. In a single woman upon whom I operated to remove a 
small uterus through the vagina the operation was attended 
with considerable difficulty; the fundus uteri was torn open 
in attempting to bring it down, and some jelly-like material 
escaped into the peritoneal cavity, which was thoroughly ir- 
rigated as soon as the operation was completed. Less than 
six months later the patient developed a mass upon the side 
of the pelvis corresponding to that into which this fluid material 
had escaped, and, upon opening the mass, material similar 
to that which had escaped from the uterine cavity was found, 
and the disease progressed and eventuated in the death of the 
patient. 

The second form of recurrence is a lymphatic gland recur- 
rence. The investigations of Poirier and Leopold have demon- 
strated that the lymphatic vessels of the middle and upper 
thirds of the vagina and from the cervix proceeded to the iliac 
glands along the course of the iliac vessels and at the sacro- 
iliac articulation in the angle formed by the separation of the 
external and internal iliac vessels. The lymphatic vessels 
of the uterine body proceed to the upper margin of the broad 
ligament and follow the spermatic artery to the vertebral column, 
where they open into the lower lumbar lymphatic glands, which 
are situated behind the peritoneum in the neighborhood of 
the large vessels. Fortunately, lymph infection occurs late 
in cancer of the uterus, so that lymphatic gland recurrence after 
total extirpation is a rare condition. After chloroform narcosis 

52 



818 GYNECOLOGY. 

the roundish, hard, immovable nodules can be recognized in the 
pelvis. 

The third form is that of metastatic recurrence in which 
the disease is carried to more or less distant organs and pre- 
sents nodules of a histologic structure similar to that of the 
primary cancer. These metastases in uterine carcinoma are 
rare, and exist only in advanced stages. 

659. {B) Inoperable. ^Unfortunately, the majority of women 
suffering from cancer of the uterus come under the observation 
of the surgeon too late and must be considered as inoperable. 
Extirpation of the uterus adds nothing to a favorable prognosis 
when the disease is so extensive, but, as much can be done in the 
way of palliation and symptomatic therapeusis, this section is 
necessarily an important one in the treatment. The treatment 
of this large division has failed to receive the consideration given 
to the operable class, but its value must not be considered trif- 
ling. It comprises not only the study of the means which will 
afford the patient temporary relief, but also those which will 
diminish her suft'ering and occasionally afford a hope of recovery. 
The great variety of methods advocated betokens the weakness 
of our efforts to oppose the ravages of the fearful disease. 

The principal indication for treatment in inoperable car- 
cinoma of the uterus is to combat such symptoms as hemor- 
rhage, discharge, and pain. The hemorrhage indicates that 
the new formation of the disease projects into the capillaries 
and small vessels, the walls of which are formed by the cancer 
structure, so that the most trifling injury or increased blood pres- 
sure results in rupture. The later suppuration results from 
wandering-in of saprophytes, which causes the structure to 
break down. The collection of blood and secretion in the 
vagina affords ready entrance to those germs which cause 
suppuration. They may invade the stn*face of the less well- 
nourished new formation. Hemerrhage and discharge are not 
always marked symptoms. The disease often makes great prog- 
ress without these severe symptoms being present. They may 
be supplanted by a severe seropurulent discharge similar to that 
which occurs in senile colpitis, while the odor can be almost 
completely absent. In old women we frequently observe hard, 
scirrhous forms of cervix cancer, which show but trifling in- 
clination to disintegrate; consequently, discharge and hemor- 
rhage are wanting, and pain is caused by the further progress 
of the new formation or is exhibited as the only distinct symp- 
tom. In such cases narcotics almost exclusively become the 
sheet anchor. 

Cases which require an aggressive treatment are those forms 
of portio and cervix cancer which are especially characterized 



GENITAL TUMORS. 819 

by vigorous growth of the new formation. The more rapid 
the proHferation, the more rapid is its transition, and, therefore, 
the earlier hemorrhage and discharge appear. The most effective 
method of treating rapidly advancing carcinoma is the removal of 
the newly formed- mass. In the more gradual development of the 
disease it progresses deeply; its superficial parts perish slowly, 
often with considerable hemorrhage, loss of fluid as offensive 
discharge, decreased appetite, and associated therewith weariness. 
Palliative operative treatment is especially suitable for the cauli- 
flower form of growth in the portio, unless the vaginal walls 
have been extensively invaded. Results are less promising 
when, with existing ulceration, is associated very severe infiltra- 
tion of the pelvic connective tissue surrounding the cervix. 
Further, when the new formation has already penetrated the vaginal 
structures, the knife should not be employed to do more than cut 
away the fungiform growth, because the wall is thin and the 
infiltration zone is often difficult to recognize. The knife is 
especially improper in cancer of the cervix when the infiltration 
has extended to a marked degree into the parametrium. In 
such cases, the sharp curet should find employment. The opera- 
tion should be preceded by a careful examination under an 
anesthetic, which is often necessary to determine contraindica- 
tions to total extirpation. The investigator should observe the 
extent to which the new formation projects into the retro-uterine 
culdesac or upon the bladder wall, for injury to such structures 
occurs easily although the rectum is rarely injured. 

Approach of the disease to the bladder is best investigated by 
the introduction of a catheter, by which the bladder is pressed 
against the palpating finger. The extension to Douglas' pouch 
is easily recognized by a digital investigation through the rectum. 
In large carcinomatous collections it is important to ascertain 
how far the cancer extends beyond the uterus. When the para- 
metrium is invaded, preparation must be made for severe hemor- 
rhage, as curet ing can easily injure the large branches of the 
uterine artery. 

Cureting is the principal palliative operation for cancer, 
but the treatment should not be confined alone to the use 
of the curet. Such treatment injures previously uninvolved 
tissue, which becomes a favorable soil' for the extension of the 
disease, and the subsequent progress is more rapid. Cureting 
should always be followed by an immediate employment of 
the cautery or by the application of some strong caustic agent 
which will destroy a large part of the infiltrated zone and reach 
tissue of a more normal character. The uterus is exposed by 
a speculum and lateral retractors. In preparation for the 
employment of the cautery the operator should be prepared 



820 GYNECOLOGY. 

to protect the vagina and external genitalia with wooden re- 
tractors. To avoid too much absorption of light from the depth 
of the cavity by their dark color, their inner surfaces should 
be coated wHth a thin layer of quicksilver. In addition are 
needed sharp curets, scissors, forceps, needle-holder, and needles, 
the latter for use in case of fistula, though they are seldom 
required. We should also have ice- water for irrigation, and 
sponges or pads or, still better, cotton or gauze pads upon long 
forceps. Although the use of the curet is not painful, it is 
advisable for the patient to be under an anesthetic, as the fear 
of burning would be so great that an effectual application of 
the hot iron could not be made. 

While the patient may not ask the character of the dis- 
ease, her fears cause her to anticipate the worst, and her con- 
fidence in what is being done for her will be dependent upon 
its apparent gravity, and the abatement of the symptoms 
which follows the procedure permits her to secure new courage. 
It is well that she should be assured that we do not expect 
to remove completely the discharge, and that subsequent treat- 
ment may be necessary. She is thus saved from utter despair 
upon the return of the discharge. 

The procedure is as follows: The patient, narcotized, is 
placed upon an operating table and the parts are cleansed 
as thoroughly as the condition will permit; the new formation 
is exposed with retractors and as much as possible of the tissue 
is scraped away with a sharp curet, reaching the firm infiltra- 
tion zone. In the softer parts of the cancer the hemorrhage 
is considerable, but becomes less as the infiltration zone is 
reached, because there the vessels still retain their contractile 
power. To limit the bleeding, then, it is important to pro- 
ceed rapidly with the curet. As we proceed, the scraped masses 
are removed by irrigation with ice-water, or, probably equally 
effectively, with water at a temperature of 120° F. The irri- 
gation enables us the better to inspect the operative field. The 
finger must be employed occasionally to judge of the progress 
and of the amount of resistance, especially of thin points, par- 
ticularly in the posterior vaginal vault and over the bladder, 
to assure ourselves that perforation will not occur and that 
the new formation has been sufficiently removed. A smaller 
curet can be employed to remove further tufts in the uterine 
cavity. Shreds and ragged masses which elude the curet are 
seized with forceps and cut away with scissors, and the bleed- 
ing is controlled by firm pressure with gauze pledgets. A 
crater-like cavity is formed, which frequently can project into 
the parametrial tissue, which is further cleansed, and from 
which hemorrhage is arrested by the use of the thermocautery. 



GENITAL TUMORS. 821 

It has been advised that the thermocautery be followed by 
coating the vaginal walls with vaselin, impregnating the diseased 
structure with alcohol and igniting it, allowing it to burn for 
one-half minute to a minute and a half, btit it is difficult to con- 
fine the injury produced by this procedure to the diseased struc- 
ture. Where there is a disposition to bleed after the application 
of the cautery, it maybe controlled by injecting with a hypoder- 
matic syringe i part of a i : looo solution of adrenalin chloridto 4 
of distilled water. After the oozing has been controlled, the ex- 
cavated cavity should be packed with a 2 per cent, solution of 
formalin. This agent has a caustic action and is more particu- 
larly selective of the malignant infiltrate. The packing must 
be carefully covered in order to protect the healthy structures 
from contact with the acrid discharges. In the most favor- 
able cases cicatrization is produced. With cicatrization the 
cavity shrinks and is much diminished. The action of the 
Paquelin thermocautery must be prolonged to be most effective. 
It must be frequently removed, because blood and shreds of 
tissue rapidly coat it. The removal is also done to permit the 
tissues to cool, that undue scorching may not occur at undesir- 
able points. When the hemorrhage is quite profuse, it is im- 
portant to bring the entire cavity at once in contact with the 
cautery. After the hemorrhage is incidentally controlled, 
we see, here and there, blood trickling and oozing from small 
points, which must be resubjected to the cautery until the 
cavity is lined by a thick, dry eschar. -Especial care must be 
exercised toward the vaginal margin, for bleeding will con- 
tinue there the longest. 

To secure a deep, dry eschar, we use irrigation with ice- 
water at intervals only in the early part of the treatment, and 
later withdraw and cool the retractors, or retain them in the 
vagina and cool with a pad wet with ice-water or, better still, 
control the oozing with the injections of adrenalin. Should these 
precautions be omitted, the vagina will become severely burned 
in prolonged operations. With the wooden retractors the danger 
of burning is lessened, but the long employment of the cautery 
will require an occasional cooling of the cavity. The procedure 
concluded, the cavity should be packed with formalin gauze. 

In properly selected and carefully managed cases the danger 
of the procedure is slight, and it can be accomplished with- 
out injury to the bladder or the peritoneum. Injuries to the 
latter are usually not serious. The hemorrhage may be con- 
siderable, though it is generally controlled without difficulty 
by the methods suggested. A ligature is rarely required, for 
the cautery is competent to control even arterial bleeding. 
In the rare cases of inoperable cancer of the uterine body great 



822 GYNECOLOGY. 

prudence must be exercised to prevent the cautery from per- 
forating the thin walls. The finger can generally enter the cavity, 
by which the weak places can be recognized and undue pressure 
against them avoided. The procedure is usually borne with 
but little discomfort. The patient will scarcely complain, unless 
we have unfortunately made an eschar upon the external geni- 
talia, which is very painful and soon becomes edematous. 

After the procedure is completed the vulva should be covered 
with vaselin, and, in the most trifling external burning, a 
pad should be applied, which is frequently wet with lead-water 
and laudanum, or a carbolic-acid solution should be applied 
to the external genitalia. Slight elevation of temperature is 
generally noticed after such operations, but they exert no marked 
influence upon the general condition, and the temperature 
subsides in a few days. 

Parametritis and septic processes are rarely observed. The 
tampon should remain five or six days. The eschar will be 
found to have partly separated under trifling suppuration, 
and the cavity will be more or less diminished. After with- 
drawal of the tampon the loose-lying tissues are carefully re- 
moved. The exercise of force must be avoided, because it 
causes hemorrhage. The cavity is sponged, and we await the 
complete separation of the slough. Treatment after the re- 
moval of the eschar is directed to the securing of cicatrization. 
Olshausen lauds for this purpose tincture of iodin. He employs 
the stronger solution: 

H . Iodin pur., i part 

Rectified spirits 8 parts. 

It is applied by a saturated pledget of cotton, which is pressed 
lightly against the cervix. The superfluous portion flows 
back into the bowl of the speculum, from which it may be used 
over and over. The alcohol is an excellent antiseptic. 

The patient should be advised to wear a napkin after the 
application to protect the clothing. The applications are made 
every two or three days until the cavity contracts and becomes 
clean. In favorable cases a watery discharge, sometimes tinged 
with blood, follows, which has entirely lost its offensive odor 
and is so slight that the patient considers herself cured. Torg- 
gler tampons the vagina with iodoform gauze saturated with 
peroxid of hydrogen and permits it to remain for three or four 
days. The surface is scraped with the sharp curet, subjected 
to the thermocautery, and covered for a few minutes with 
cotton soaked with a 40 per cent, solution of formaldehyde. 
Six to ten days later a slough is thrown off, which leaves a dry 
wound. 



GENITAL TUMORS. 823 

Caustics. — Sims followed the use of the curet by an appHca- 
tion of zinc chlorid solution. Hemorrhage was controlled by- 
pledgets wet with a solution of persulphate of iron, which were 
removed and followed by tampons wet with the zinc solution. 
Van de Warker used a 50 per cent, solution of the chlorid of 
zinc. After the 'use of the curet small pledgets, squeezed from 
a 50 per cent, solution of zinc chlorid, are placed against the 
diseased surfaces. The healthy tissues are previously pro- 
tected from injury by an ointment of bicarbonate of soda in 
vaselin. These medicated pledgets are so placed as to come 
in contact with the entire diseased surface; over them a piece 
of dry absorbent cotton or gauze is laid, after which the vagina 
is filled with a wad of cotton wet with a saturated solution of 
bicarbonate of soda. 

The carbonate causes a decomposition of the zinc salt, w^hich 
renders it nonirritating to the tissues. The nurse can press the 
superfluous agent out of the pledgets without injury to her fingers 
by first anointing them with vaselin. Without the precaution 
above directed, the vagina, and especially the introitus, would 
be badly burned ; indeed, in spite of every precaution the vagina 
is frequently seriously injured. Where the wall is thin, as over 
the bladder, the weaker solution (5vj to f.^j) employed by Sims 
should be substituted. Sims left the tampons undisturbed for 
four or five days, unless earlier removal was indicated by eleva- 
tion of temperature. He ascribed to the agent no especial influ- 
ence upon the cancer beyond its active destructive effect, but 
Van de Warker believes the drug to have a special affinity for 
the cancer tissue, selecting it and leaving the healthy tissue. The 
microscopic investigations of Ehler upon this subject, however, 
demonstrate the contrary — that the cancerous tissue is only super- 
ficially affected, while necrosis of the healthy tissue extends to a 
considerable depth. Frankel employs the zinc salt, but previ- 
ously scorches the surface with the thermocautery. He leaves 
the pledgets in contact with the affected surface for twenty-four 
hours. Great care must be exercised in the cases for which this 
treatment is employed. Should the bladder or posterior vaginal 
wall be infiltrated, or if these parts are insufficiently protected, 
fistulse may form, which greatly aggravate the subsequent con- 
dition of the patient. A slough resulting from the application 
may open the bladder, rectum, or peritoneal cavity. During or 
following the separation of the slough, a hemorrhage so severe 
as to cause a fatal result may readily occur. When the slough 
has separated, exuberant granulations develop, and later strong 
cicatricial contraction and shrinking, which Fritsch indicated as. 
the cause of extraordinarily severe pain, which is aggravated by 
the increased infiltration above the scar tissue. 



824 GYNECOLOGY. 

Ricard relates the history of a patient in whom hematometra 
and hematosalpinx followed the introduction of zinc chlorid 
pencils into the uterus. The scar tissue was so dense that the 
collection could not be reached per vaginam, and the woman 
perished from hemorrhage after laparotomy. The cervix and the 
greater part of the uterus had degenerated in cancer. Many 
patients in whom this treatment has been employed have been 
so much improved as fully to justify its practice in similar cases, 
but strong solutions and the paste should be absolutely in- 
terdicted. 

Fraipont advocates the use of liquor ferri sesqui chloridi, from 
which he obtained excellent results. This agent has a superficial 
action upon the surfaces to which it is applied, and forms a 
slough, following the discharge of which hemorrhage is likely to 
recur. The bleeding following the curetment can only be incom- 
pletely controlled by pressure with an iron solution. A better 
application is a tampon of iron chlorid. Cotton is saturated with 
this substance and packed against the surface. These pledgets of 
cotton form hard lumps, w^hich are difficult to move, and are 
only slowly separated under strong suppuration or discharge. An 
early attempt at their removal is attended with severe pain and 
hemorrhage. 

Leopold advocates the use of a concentrated carbolic acid 
treatment which he continues from one to two months. After 
radical scraping and scorching with Paquelin's cautery he follows 
it by cureting the surface every three months and plunging 
the cautery into the new-growths so that the tissue is rapidly 
scorched. Chrobak used, after cureting, repeated cauterization 
with nitric acid. Out of sixty-five cases so treated, he attained 
good duration results. In one of these cases, after radical slough- 
ing of the carcinoma of the cervix three years and nine months 
later, because of the strong scar tissue, there had formed a hema- 
tometra, which was emptied twice. In other cases after repeated 
cureting and cauterization strong scar formation was seen at the 
end of three years without recurrence. The third patient still 
lived five years after operation, free from recurrence. 

This treatment does not seem to have stood the test of time, 
and is now scarcely considered. Goodell advocated in inoper- 
able cancer the use of applications of powdered pepsin and sal- 
icylic acid — pepsin to digest and eat off the diseased tissues, 
salicylic acid to prevent decomposition. Cucca and Ungara 
advocate tampons wet with: 

R . Methyl-blue gr. xc 

Alcohol (95 per cent.), 

Glycerin, aa f 5 iij 

Water, f ? vij. M. 

Apply to the diseased surface. 



GENITAL TUMORS. 825 

It arrests hemorrhage, aborts discharge, and prolongs hfe. 

Parenchymatous Injections. — Various agents have been em- 
ployed as injections into the structure of the cancer with a view 
to moderating its course or destroying it. Thiersch used nitrate 
of silver; Schramm, chlorid of sodium and sublimate. Mosetig- 
Moorhof and Stilling employed pyoktanin. Schultze has lately 
used injections of absolute alcohol in a large series of cases. Bern- 
hardt employed a 6 per cent, solution of salicylic acid in 60 per 
cent, alcohol. Vulliet, independently of Schultze, has practised 
the treatment with absolute alcohol. Under this treatment the 
bleeding and discharge were trifling or ceased entirely. After ten 
or fifteen injections the evil smell of the discharge disappeared 
and the pain ceased. Treatment, in the beginning, should occur 
at intervals of a few days. During the intervals the vagina may 
be tamponed with iodoform gauze. In the course of weeks or 
months the ulcer heals and the infiltrate disappears. Schultze 
suggests that Avhen the injection is in the neighborhood of the peri- 
toneum, the after-treatment is painful. Schramm found the in- 
jections painful and without special influence. The treatment 
has to be continued over weeks and months — a requirement that 
can be carried out onl}^ in rare cases. Without question, better 
results Avill be obtained by the use of the curet and the thermo- 
cautery. 

A. Martin, in inoperable cases, advocates suturing the wound 
surface occasioned by the curetment. The carcinomatous masses 
are removed with the sharp spoon and the parametrium is ligated ; 
then, drawing down the uterine stump, strong curved needles are 
passed under the entire w^ound surface to the border of the neck 
or to the mucous membrane, and the thread is so secured that it 
brings together the wound surfaces created by the curetment. In 
a very extensive wound the entire pelvic body is protected by a 
mattress suture, when the mobility of the stump is so limited that 
it is impossible to accomplish the partial sewing of the wound 
surface. The vagina is so sutured in the depth of the crater that 
a continuous series of firm sutures come to lie about the opening. 
The operation, however, is frequently impracticable, because ex- 
tensive cavities with strong infiltrated walls are involved. The 
advantages offered by the method are that hemorrhage is 
securely controlled and that after-hemorrhages do not appear. 
The patient is spared the suppuration which follows the caustic, 
and it forms a firm scar. Houzel and Chrobak have seen good 
results from suturing. The method, however, is applicable only 
to a limited number of cases, and frequently offers great technical 
difficulties. Sutures will often cut through the carcinomatous 
tissue ; sometimes the wound surfaces break apart, and suppura- 
tion again follow^s. The reported good results are less from the 



826 GYNECOLOGY. 

suture of the wound surface than from the union with the para- 
metrium. 

A class of cases will be found in which the disease is so exten- 
sive that no palliative operation will afford relief, but the phy- 
sician endeavors to make the patient comfortable and must 
relieve the distressing symptoms. These are hemorrhage and pro- 
fuse offensive discharge. The latter becomes so disgusting as to 
be distressing to the patient and to those about her. Local treat- 
ment is demanded. Syringing and tamponade with wet or dry 
dressings come under consideration. The control of hemorrhage 
is accompHshed more effectually by the tamponade than by 
syringing with astringents. Kehrer emplo3^ed the tampon with 
cotton gauze saturated in an 8 to lo per cent; solution of acetic 
alum. Iodoform gauze also exercises a good influence upon the 
smell of the discharge, but through long employment the odor 
of the iodoform becomes persistent and annoying. 

The dry treatment, introduced by Sanger and employed by 
Fritsch, often proves beneficial, though it requires medicinal help 
in order to carry it out. It may be employed alternately with 
injections. The dry treatment follows curetment and cauteriza- 
tion. Iodoform is blown into the vagina, which is then firmly 
tamponed with iodoform gauze. Tamponades covered with iodo- 
form may be introduced, and may remain as long as possible. 
This treatment should be repeated once or twice a week for some 
time. It controls hemorrhage, but especially keeps down the 
unpleasant smell of the discharge. The unpleasant odor of the 
iodoform and the existing danger of intoxication have led to the 
substitution of tannin and boric acid and salicylic acid for similar 
purposes. Torggler employed charcoal powder with iodoform, 
which deodorized the mixture; the ulcerated surfaces were rap- 
idly cleaned. Long-continued sitz-baths often have a beneficial 
influence and afford the patient great relief. When penetration 
of the bladder occurs, the patient may keep herself comparatively 
comfortable by Avearing a urinal. 

It is important that the patient should be kept out of bed as 
long as her strength will permit. When once she becomes bed- 
ridden, her condition is made worse, and the psychic depression 
is more marked. It requires the greatest cleanliness and most 
continuous care upon the part of the nurse to limit the occur- 
rence of bed-sores, as the continuous and abundant discharge 
keeps the parts wet, and in emaciated persons with feeble powers 
of resistance the skin becomes broken and extensive bed-sores 
follow. In these enfeebled patients it is not to be expected that 
the loss of substance will be recovered, and scarcely that the 
wound surface can be kept clean. By the processes of absorption 



GENITAL TUMORS. 827 

from the wound surface and the breaking-down cancer, the 
patient soon has regular elevation of temperature, which aggra- 
vates the discharge. It is not w^orth while giving antipyretics 
for the elevation of temperature in these cases, as they have but 
trifling influence, and soon break down nutritive processes. A 
mixture of salol and aristol has been employed with advantage. 
When the patient is unable to be continuously under medical 
treatment, resort must be had to irrigation. The entire series of 
antiseptic means have been employed; injections of permanga- 
nate of potash, one to two teaspoonfuls of 5 per cent, solution in 
a gallon of water, is one of the best. The drug is cheap, and 
possesses the advantage that the patient is using a substance that 
does not irritate or burn, is completely odorless, and is an excel- 
lent disinfecting fluid. It has the advantage over the phenols 
that the peculiar smell of the latter, mixed with that of the 
cancer discharge, soon annoys the patient. Martin recom- 
mended for a deodorizing injection a solution of 3 per cent, hy- 
drogen peroxid with i per cent, thymol. Various astringent 
fluids, as pyroligneous acid and alum solution, are favored. 

If penetration of the bladder and rectum has already resulted, 
the patient is in a condition which makes it impossible to render 
her comfortable. Tampons saturated with fatty or oil}^ mix- 
tures, such as bismuth salve, can be employed. The discharge 
is thus sometimes held back, but the continued irritation of the 
parts results in an excoriation eczema of the external genitalia, 
which is a new source of torment for the unfortunate patient. 
In such cases the removal of the disagreeable odor is no longer 
possible. In patients suffering from edematous external geni- 
talia covered with excoriations and ulcers, and from already 
existing edema in the lower extremities, irrigation is very difficult, 
and is practicable only under increase of pain. Covering the 
lower extremities with a rubber skirt, by which the odor is pre- 
vented from rising, has been advocated, but the moist warmth 
thus engendered soon renders it unbearable. Fritsch advocates 
completely covering the vulva and the inner surface of the thighs 
Avith frequently changed pads wet with chlorin water, and thus 
destroy as much as possible the offensive odor. 

When the disease is far advanced, neither the greatest clean- 
liness nor the admission of fresh air to the sick-room is sufficient 
to drive out this odor, and the patient becomes a source of dis- 
comfort to herself and to those who attend her. Anorexia makes 
itself noticeable early. This is undoubtedly due to the influence 
of the sickening odor upon the appetite. Every form of food be- 
comes absolutely repugnant, and the patient is obliged to confine 
herself then to the smallest quantities of liquid nourishment. 
Sometimes these are more readily taken when cold. Patients 



828 GYNECOLOGY. 

frequently live for a remarkable length of time with scarcely any 
nourishment. The relief occasioned by the removal of the odor 
usually results in the improvement of the appetite. Obstinate 
constipation becomes a marked symptom, which also acts unfa- 
vorably on the appetite. When evacuation occurs, it is so 
extraordinarily painful, because of the hard infiltration in the 
pelvis, that the patients are constrained to avoid defecation in 
order to escape the pain. Large enemas are better than purga- 
tives in such cases. An enema of one-half to one pint of kero- 
sene will frequently have a salutary effect in emptying the 
bowel. Of course, if a rectal fistula exists, the enema can 
not be employed. The uncontrollable vomiting which marks the 
advent of a uremic condition is an exceedingly distressing symp- 
tom. Occasionally, the administration of diuretics will relieve 
it. The condition of the urinary secretion should be observed; 
any failure should be an indication to administer diuretics, by 
which the appearance of vomiting can be prevented. 

In the later stages the third distressing symptom is pain, 
which can be avoided only by the free use of narcotics. The only 
hesitation in the administration of narcotics should be to avoid 
their too lavish use early. The patient who becomes accustomed 
to large doses of the narcotics, when she reaches a stage at which 
they are still more seriously needed will have become so inured 
to the drug that she can no longer find relief. Early in the dis- 
ease it is better to employ remedies which will give a slight 
anodyne effect in place of the narcotics. Antipyrin has been 
found effective. In extensive infiltration involving the lateral 
and posterior parts of the pelvis this remedy is useless. Such 
cases are relieved by rectal suppositories containing : 

H . Morphin sulph., gr. i 

Pulv. opii pur., gr. | 

Pulv. belladon., gr. | 

01. theobrom , ad gr. xx. 

Ft. supposit. 

Such a suppository, given at night, relieves the distress, secures 
sleep, and delays the need for the larger doses of morphin. An 
additional advantage is that by such a combination we can in- 
crease the dose and give the patient the prescribed daily ration 
which she will require. Codein may be given in pill form. In the 
later stages of the disease only the subcutaneous employment of 
large doses of morphin will afford relief. Fortunately for the 
patient and her relatives, toward the end of the disease the com- 
pression and obstruction of the ureters occasionally cause 
sufficient uremia to obtund the general sensibility and lessen the 
discomfort. The soporose and comatose conditions are frequent, 
and increase the comfort of the patient. Cumston's proposition 



GENITAL TUMORS. 829 

to relieve the obstruction by establishing a ureteral fistula or 
performing a nephrotomy should receive no consideration. In 
advanced stages Drszewczky claims benefit from an ointment of 
extract of condurango and vaselin. 

660. Pregnancy, Complicating Carcinoma. — We have already 
spoken of the occurrence of pregnancy as a complication of car- 
cinoma — a complication which is fraught with the greatest danger 
to two lives. It was stated that the treatment would entirely 
depend upon the progress of the disease. Thus, if the disease 
was inoperable, and there was no possible chance for the mother, 
every effort should be made to prolong the pregnancy to full 
term or to viability of the child, in order that it should have a 
chance for its life; when, however, the disease is operable and 
there is hope for a radical cure of the patient, no consideration 
for the child should operate against the mother's chances. The 
continuation of the pregnancy is doubtful, and it is attended with 
improbability of the child being delivered alive. Danger to the 
mother is very greatly increased, with almost the certainty that 
the progress of the disease will be so rapid that at the termination 
of pregnancy the time for radical treatment will be found to be 
past. Under such circumstances the proper consideration is the 
life of the mother. If the pregnancy has not reached the fourth 
month, we may proceed to the removal of the uterus per vaginam. 
Emptying the uterus reduces its size and renders easier its sub- 
sequent removal through the vagina. During and after the 
fourth month the operation should be performed through the 
abdomen. Between the fifth and seventh months we may be 
governed by the condition as to whether we w^ait for viability 
or proceed to immediate operation. If the disease is apparently 
progressing rapidly, an operation should be done immediately, 
without regard to the child. We may resort to an abortion, 
and then operate through the vagina, or the abdomen ipay be 
opened. In advanced pregnancy Martin has advocated the 
supravaginal amputation of the uterus and the extirpation of 
the carcinomatous cervix by the vagina. The advantages of 
this procedure are that the abdomen is kept open but a short 
time, that the hemorrhage can be better controlled from below, 
and that the carcinomatous masses are not draAvn back through 
the abdominal cavity. Of six patients thus operated upon, 
one died of septic peritonitis. In the last two months of preg- 
nancy we have to consider the treatment which has in view 
the preservation of two lives. Cesarean section should be per- 
formed, which is followed by a Freund abdominal, the Zweifel 
combined, or, finally, the pure vaginal total extirpation. Of 
these procedures, the abdominal operation seems preferable. 

We come next to the consideration of operable carcinoma in 



830 GYNECOLOGY. 

labor. Here we have the possibiHty of a spontaneous ending of 
labor through the diseased passages. This may be considered, if 
the disease is still in the early stages. If the carcinomatous infil- 
tration has not involved the entire portio, and a more or less 
large zone of the uterine margin remains free and capable of 
dilating, the ovum may be thus extruded. When the carcino- 
matous masses can not be crushed by the head, they should be 
cut away with scissors or the thermocautery as a preliminary, 
and the child should be delivered by forceps or by version. If 
the ovum is dead, its size may be diminished by perforation or 
by piecemeal operation, whichever will end the labor most effect- 
ively and in the best manner for the mother. Following the 
delivery we may consider immediate vaginal total extirpation, 
or its delay until the second week of the puerperium. The delay 
in these cases is suggested because of the size of the uterus. The 
advantages of the procedure, however, are that the uterus permits 
itself to be readily drawn down to the vulva, and that the wall 
of the vulva and the vagina have been so distended by the pas- 
sage of the fetus that they do not afford an artificial hindrance. 
Occasionally, the size of the uterus affords difficulty. It can then 
be reduced by splitting it into two parts in the median line, but 
this endangers the reinfection of the wound. 

66 1. Summary. — In the discussion of the subject of cancer I 
have endeavored to give a comprehensive view of the methods 
by which the disease can be combated. As such a statement 
must be, however, more or less confusing to the student, it is 
my purpose in this section to briefly present the indications for 
special treatment. The two principal methods of treating 
operable cancer are by the abdominal and vaginal routes. The 
sacral method affords no advantages which render it worthy of 
consideration. When the uterus is large and the disease has 
evidently extended to, if not into, the parametrium and is com- 
plicated with myoma, ovarian tumor, or the later stages of 
pregnancy, or w^hen the vagina is undilated and narrow, ab- 
dominal hysterectomy should be preferred. Vaginal hysterec- 
tomy when carcinoma is limited to a uterus freely movable, not 
too large and accessible through a roomy vagina, has been the 
operation of election. The after-results, however, have demon- 
strated that vaginal hysterectomy, as ordinarily performed, is 
ineffective in that it does not afford opportunity for the removal 
of sufficient tissue to insure against early recurrence. The 
operator should keep two objects in mind in proceeding to per- 
form any operation for carcinoma : ( i ) To insure the removal of 
a diseased organ in a healthy field, which is accomplished where 
possible by the removal of the upper part of the vagina and 
as much parametrial tissue as safety for the ureters and bladder 



GENITAL TUMORS. 831 

will permit, thus getting beyond the isolated nests, which may 
be situated in the parametrium; (2) the exercise of such pre- 
cautions as will avoid the implantation of cancerous material 
upon the healthy wound. 

In the vaginal pperation we have the choice of three methods 
of procedure for the control of hemorrhage. These are the 
employment of pressure forceps or clamps, the electric cautery, 
and the ligature. The clamp procedure has the advantage of 
being more expeditious, enabling us to remove the uterus in 
favorable cases in a very few minutes. It has the disadvantage 
that it produces an increased amount of pain, from the weight 
and dragging of the clamps and the necessity of the patient being 
confined to the dorsal position. The retention of the clamps 
produces a certain amount of necrotic tissue in the peritoneal 
cavity after removal of the clamp, and causes increased danger 
of septic infection. The removal of the clamps, often as late 
as forty-eight hours, is sometimes attended Avith quite free after- 
bleeding, which may require their reapplication, under very great 
disadvantage, in order to prevent the death of the patient from 
hemorrhage. In a large hospital Avhere there is a convenient 
electric-light plant or connection with the street current can be 
made, the electrocautery is ideal, otherwise it means the employ- 
ment of special apparatus, which is cumbersome and requires 
expert skill to manage and maintain in order. The ligature mtcthod 
is slower than the clamp, but the hemostasis is more sure and the 
comfort of the patient is enhanced during convalescence. Cat- 
gut is preferable to silk for the ligature, because the latter liga- 
ture is likely to become infected, after which the silk will cause a 
sinus granulation and a discharge, which continues until the 
ligature disintegrates, sloughs away, or is removed, and causes 
worry and distress to the patient, inducing her to believe that 
the disease has recurred. 

In performing an abdominal hysterectomy the method sug- 
gested in Section 578 is the proper course. The uterine arteries 
should be ligated separately near their origin, the course of the 
ureters observed, and an extensive removal of the parametrium 
and upper part of the vagina made. This procedure, in my 
judgment, is more important than the removal of glands. Before 
closing the wound, bleeding vessels are carefully secured. AYhen 
there is much oozing or a large surface has been denuded of 
peritoneum, gauze is carried through the opening into the vagina, 
packed into the cellular tissue upon each side, and the peritoneum 
united over it by a continuous catgut suture. The abdominal 
cavity is cleansed ; the wound is closed as in ordinary abdominal 
procedures. The gauze packing in these cases may be left in for 
fromi six to eight days and then removed through the vagina. 



832 



GYNECOLOGY. 



662. Chorio-epithelioma Malignum. — Some fifteen 3/ ears ago 
a condition was recognized as a form of malignant disease which 
is intimately associated with pregnancy. (Fig. 531.) It has 
been described under the various names of deciduoma malignum, 
deciduomatous sarcoma, sarcoma deciduo-cellulare, blast oma, 
deciduo-chorion cellulare, syncytium carcinoma, syncytio malig- 
num, the destructive bladder mole, destructive placental polyp, 
and the title of our section, chorio-epithelioma malignum. 
These various designations indicate the attempts upon the part 
of the different investigators to name the structural origin of the 




Fig- 53^- — Chorio-epithelioma of the Uterus. 
a. a. a, a. Nodules of neoplasm, h. Stump of round ligament, c. Thrombus pro- 
jecting from ovarian artery. 



condition. (Fig. 532.) It was formerly supposed to be due to 
the degenerative changes resulting from a cyst mole, from which 
metastases were carried by the veins to different points, and 
growths of the similar epithelial structure followed. Later in- 
vestigations, however, have disclosed that the mole is not neces- 
sary to its development, although favoring its growth. Later in- 
vestigators agree with Marchand that it arises from the syncytial 
cells, although there is still w^ant of agreement as to whether these 
cells are fetal or maternal (page 833). 

Etiology. — The disease occurs during the period of active 
reproductive life and follows an abortion, either intra-uterine or 
tubal, a normal labor, and frequently a hydatid mole. The dis- 
ease is not necessarily dependent upon pregnancy, for it has been 
recognized in the unmarried woman and in the testicle of the 



GENITAL TUMORS. 



833 




Fig. 532. — Chorio-epithelioma Malignum. (Section furnished bv Drs. C. P. 

Noble and S. E. Tracy.) 
a, a. Large syncytial cells, b, Blood detritus. 



/c;^^- 







b-^ 



Fig. 533. — Histologic Section of Chorio-epithelioma. 
a. Collection of large decidual cells, b, b, b, b. Chorionic villi showing proliferation 
of their cellular coverings. c. Large multinucleated cell containing a vacuole. 
53 



834 GYNECOLOGY.' 

male. In such cases it has arisen from inclusion cells. It has 
been attributed to want of nourishment in the villi. The condi- 
tion has occurred during pregnancy, as Pick reports a case in 
which a tumor was situated in the posterior wall of the vagina, 
which, upon removal, contained distended chorionic villi with 
proliferated syncytial cells. 

Symptoms. — In a few days to a few months following the 
termination of a pregnancy a patient suffers from repeated 
bleeding, increasing in severity, the patient becoming markedly 
anemic. There will also be a profuse dirty, watery discharge. 
The continued drain, the hemorrhage and discharge, give rise to 
extreme weakness and a cachectic appearance. Curetment of the 
uterus in a condition like this results in the removal of a varying 
quantity of soft, friable material, which looks like placenta and 
bleeds freely. Oftentimes it will contain necrotic tissue, causing 
an extremely offensive odor. Very frequently a metastasis in 
the form of small round masses will be observed on the anterior 
wall of the vagina, which, on being opened, will present tissue 
similar to that removed from the uterus. Similar metastases 
result in the formation of growths in other portions of the body. 
Thus we may find it carried to the lungs, pleura, diaphragm, 
spleen, pericardium, kidney, liver, intestines, and even the brain. 
When the diseased tissue is cureted from the uterus, the patient 
has but temporary relief ; hemorrhages again return, and a second 
curetment will remove tissue similar to that which was found 
in the first employment of this instrument. 

Diagnosis. — Diagnosis is easy in the advanced cases, but diffi- 
cult in early stages. It is determined both by clinical observation 
and microscopic investigation. The rapid return of hemorrhage 
after the curetment, in which no fetal products are found, the 
foul discharges, the profound anemia,, elevation of temperature, 
large uterus, dilated os, soft friable tumor, and the metastasis, 
with the revelations of the microscope, should render the diag- 
nosis positive. The disease so closely resembles both carcinoma 
and sarcoma as to render it difficult to differentiate between 
them. Its structure having no stroma and being disseminated by 
the blood-vessels rather than by the lymphatics, makes it closely 
akin to sarcoma. From sarcoma, however, it is differentiated 
by the fact that it is composed largely of epithelial elements. 

Prognosis. — The prognosis is extremely grave. The only hope 
will be in its early recognition and the prompt extirpation of the 
uterus. Marchand reports twenty-eight cases with twenty-four 
deaths. It is one of the most malignant of growths, and gen- 
erally terminates in six months, whether operation is done or not. 
Veit reported recovery after metastases had occurred, but this 
is contrary to the general experience. In the extirpation of the 



GENITAL TUMORS. 



835 



disease the abdominal operation is preferable, for the reason 
that there is less danger of fragments of the tissue being forced 
into the veins. 

663. Endothelioma Uteri. — A recently recognized form of 
malignant disease which occurs in various tissues of the body 
is known as endothelioma, and has its origin in the endothelial 
lining of the blood- and lymph- vessels and the serous membranes. 
These growths manifest themselves in many ways, according to 
the structures involved and the particular endothelium from 
which they have originated. (Fig. 534.) The disease may occur 
in the cervix, although extremely rare, and is very similar to that 




Fig. 534. — Endothelioma of the Uterus. ^ 

a, a. Endothelial cells infiltrating lymph-spaces, h. Blood-cells, c. Connec- 
tive-tissue matrix. 



of the squamous-cell carcinoma, and the diagnosis can only be de- 
termined by the employment of the microscope. The examina- 
tion of the section of tissue reveals the squamous epithelium intact, 
free from any infolding process projecting into the underlying 
tissue. The growth consists of spaces lined by one or more layers 
of cells, resembling lymph-spaces. Where these spaces are ob- 
literated by masses of proliferative cells, there is a resemblance 
to the squamous nests, but in the latter the outer layer assumes 
a cuboidal or more cylindrical form and the nuclei are more 
vesicular. (Fig. 533.) When the disease involves the body of 
the uterus, it is likely to form a tumor of considerable size, 



836 GYNECOLOGY. 

and in its course and progress will resemble sarcoma. Metastases 
usually occur through the blood-vessels. In my own experience, 
I have noted that it is very prone to extend upon the peritoneal 
surface and result in the formation of numerous nodules over 
the peritoneum, and even eventuate in intestinal obstruction. 
Unless the latter symptoms occur, the disease is singularly free 
from pain, the patient complaining rather of the progressive 
emaciation and the continuous loss of strength. The prognosis 
is very unfavorable, since the disease progresses by both the 
lymph- and blood-vessels, but more frequently by the latter. 

664. Sarcoma Uteri. — Sarcoma of the uterus can involve 
either the mucous membrane or the wall of the organ, and 
hence is divided into two groups. Clinically it is found either in 
the body or in the cervix,— more frequently in the former, — 
and this holds true in both its anatomic varieties. Sarcoma of 
the mucous membrane is one and one-half times more frequent 
than the same infection of the wall. It differs from carcinoma 
in that it is a growth which springs from the connective-tissue 
cells, the latter from the epithelial. 

665. Varieties. — Sarcoma is divided into sarcoma of the cervix 
and sarcoma of the body. Sarcoma of the cervix occurs generally 
as grape-like clusters, protruding from the cervical mucous mem- 
brane, and it is also called sarcoma colli uteri hydropicum pa- 
pillae, and, from its grape-like appearance, sarcoma botryoides. 
From their soft appearance they have been described as myxo- 
matous, but Pfannenstiel says this condition is due to a form 
of lymphedema. In the body of the uterus the disease may 
occupy the mucous membrane or the mural structure of the 
organ, and be either diffuse or circumscribed. Sarcoma of the 
uterine wall arises in either the mural portion of the uterus or 
from degeneration of a fibromyoma. The latter origin is regarded 
as the more frequent. It is often very difficult to make certain 
whether the disease has originated as a primary sarcoma of the 
wall or from a myoma. When it is recognized as situated in a 
myoma or surrounded by myomatous tissue, the latter is evi- 
dently its source. Where the myoma is associated with a sar- 
coma which involves the adjoining tissue as well, the origin may 
remain doubtful. Sarcoma of the mucous membrane overlying 
a fibroma is not infrequently observed. 

666. Pathology. — Sarcoma involving the mucous membrane 
occurs in the diffuse and polypoid forms. The former does not 
necessarily involve the entire surface, like a fungous endometritis, 
but appears as a more or less circumscribed growth, from the sur- 
face of which there are irregular projections, giving the new forma- 
tion a roughened, often villous appearance. The polypoid variety 
is nearly three times as frequent, both in the body and in the 



GENITAL TUMORS. 



837 



cervix. Sarcoma of the mucous membrane is twice as frequent 
in the body as in the cervix. The grape-like clusters, already 
mentioned, protrude from the external os by the pedicle. The 
extremities of these are soft, oftentimes easily broken down, 
and they form a dense cluster, projecting from the os, in which 
the different portions of it are molded or flattened by pressure. 
They arise by a firm, more or less broad pedicle from the mucous 
membrane of the cervical canal and project from the external 
OS into the vagina, showing a great resemblance to the bladder 
mole. While the foundation part of the new formation of the 
cervical canal consists of firm, fibrous tissue, the vaginal portion 




Fig- 535- — Sarcoma of the Body of the Uterus. ^ 

a, a. Characteristic appearance of blood-vessels minus distinct wall, the wall 
being formed by the malignant cells. 



is strongly edematous, soft, almost fluctuating, and easily broken 
down. The growth has a pedicle which is often thinned and 
drawn out, made up of a number of individual berries which 
are situated so close together that they are flattened. (Fig. 535.) 
These vary in size from a grain of corn to that of a grape, and 
their stalk shows a smooth, moist, glistening surface of a yellow- 
ish-white, brownish, or blue-black color, alterations which are 
produced by the entrance of blood into the tissues. The berries 
are most often bluish in color, and in some places vitreous 
changes are seen. The berry contains a bright or light yellow 
fluid and collapses upon its escape. These projections, however, 



838 GYNECOLOGY. 

usually have about the appearance, if not the consistency, of 
a mucous polypus. The growth takes its origin from the superior 
layer of the mucous membrane and assumes the grape-like form 
only after its extrusion into the vagina. This form is produced 
by interference with the circulation from pressure upon the 
pedicle, which, as a rule, causes edema and swelling of the intra- 
vaginal portion. The disease progresses slowly, but is often 
carried and disseminated by the blood-vessels. The individual 
cells are mostly of the roundish or spindle form. Betw^een them 
is almost uniformly found a very fine intercellular substance. 
Parts of the new formation are divided b}^ fissures or ramifying 
spaces, which, from the high cylindric epithelium and the nuclei 
situated in the cells, are recognized as the cervical glands. These 
glands are not sufficiently numerous to justify the appellation of 
adenosarcoma, a term sometimes applied to the condition. The 
diffuse form affects the body. Its progress is slow and it extends 
upon the surface, showing great reluctance to the invasion of 
the subjacent wall. As it follows the surface it is manifested 
by large or small nodular papillary or villous projections. The 
mucous surface begins to degenerate and hemorrhage appears. 
In rare cases the muscular structure is rapidly involved. Gener- 
ally the tissue involved exhibits a reduction in its vascularity. 
When the vessels are specially abundant, it is designated as the 
hemorrhagic or telangiectatic variety. 

The appearance of a section of sarcoma is quite varied. The 
less the connective tissue present, the more homogeneous it 
appears. Most generally it is marrow-like, and, in advanced 
stages, presents a soft, smeary, and very fragile mass. With an 
increase of the connective tissue the borders are folded and irreg- 
ular, inclosing a homogeneous section. The structure undergoes 
marked changes under myxomatous alteration or serous penetra- 
tion, and not infrequently apoplectic nests are recognized and 
cysts are formed. 

The muscular walls are especially resistant, and become 
thickened, while the disease extends in the direction of the least 
resistance, w^hich is into the cavity of the uterus. The uterus is 
usually not enlarged; when it becomes so, it is uniform. The 
uterus is hard or soft, according to the degree of extension. In 
rare cases the growth of the disease and uterine hypertrophy are 
simultaneous. Under these circumstances it attains to the size 
of a child's head; in rare cases it shifts to the internal os and 
causes severe hemorrhage, serous discharge, or purulent destruc- 
tion. In rapid extension the tumor can reach the ribs. Occa- 
sionally it penetrates the uterine wall, projects upon the perito- 
neal surface, involves the peritoneum or the intestine, results in 
suppurative peritonitis, and death rapidly follows. It can become 



GENITAL TUMORS. 839 

encapsulated and penetrate the intestine or the abdominal wall, 
and form a fistula. Fistulae of the rectum and bladder are rare 
in sarcoma, but frequent in carcinoma. The disease seems 
inclined to limit itself to the uterus, and metastasis to other 
organs occurs late. The disease can grow through the uterus 
and involve the parametric tissue, but this only in advanced 
cases. A polypoid growth may extend and fill up the uterine 
cavity and lie upon healthy tissue without involving it. 

Sarcoma of the wall appears in a rounded form, with folded 
or lapped borders. The uterus is hypertrophied. Section of 
such a tumor shows a yellowish-white or grayish-red surface. 
The discharge is a milky, soft tissue, and its structure would 
indicate that it had originated in a fibromyoma. It is very 
difficult to decide whether the myoma is a cause or a coincidence. 
A myoma is not infrequently situated near a sarcoma of the 
mucous membrane, from which it can become involved. Polypoid 
growths are occasionally the size of a fist, and may have a broad 
base or a long, thin pedicle. When a polypoid growth pushes 
into the cavity, the remaining portion of the mucous surface may 
remain long uninvolved. The existence of the new formation 
develops an inclination to expel it as a foreign body, by which 
the OS is dilated, and the tumor, hanging by a pedicle, is ex- 
truded into the vagina. Portions of the tumor may disintegrate 
and be discharged. The cervical form of the species is rare, 
but sometimes projects from the os as a grape-like cluster, which 
may fill out the vagina and may even project from the vulva. 
These polypi most frequently originate from the posterior cervical 
wall and are soft growths, which show but little inclination to 
break down. 

A second form resembles the cancroid, but is softer, less easily 
broken down, and does not so rapidly seize upon the other lip. 
The spindle-cell structure predominates in the cervical tumors. 
Myxosarcoma and angiosarcoma are very frequent. Sarcoma of 
the cervix shows but little disposition to invade the uterine body 
or the vaginal vault. It most frequently penetrates the cellular 
tissue of the parametrium. 

Growths are described as spindle-celled or round-celled, ac- 
cording to the variety of these cells which predominate, as none 
are pure. The diseased structure is surrounded .by a zone of 
irritation cells, which are difficult to distinguish from the small 
round cell. Weil reported the growths occurring in the relative 
frequency of 35 per cent, spindle-cell, 45 per cent, round-cell, 
and 25 per cent, mixed-cell tumors. 

Ruge recognizes four groups : First, giant -cell sarcoma. The 
cells of the intervening gland tissue are largely increased. The 
cells — of round, sometimes spindle, form — are irregularly ar- 



840 GYNECOLOGY. 

ranged, and their nuclei often exceed in size the usual cells. 
Second, the intermediate tissue cells, which are changed in the 
large spindle form to resemble the decidua cells. They are dif- 
ferentiated by their size, situation, and irregular form. Third, 
small round or spindle cells, between which lie irritation cells. 
Fourth, smaller round-cell sarcoma, which shows a great increase 
of cells, irregular in size and form. 

The influence upon the glands of the mucous membrane gives 
variety. Generally, the glands are compressed and disappear, 
but occasionally they are retained, and form extensive areas 
within the tumor, producing what is known as adenosarcoma. 
The origin of sarcoma is difficult to fix ; the microscopic appear- 
ance would indicate that it was from the coats of the vessels. A 
tumor in which there is a great increase of the vessels is known 
as an angiosarcoma. 

Disturbances in nutrition cause edema and swelling of the 
cells; this condition simulates myxomatous degeneration, and 
has been called myxosarcoma. Lymphosarcoma is the name 
applied to those cases in which the disease originates in, and 
follows the course of, the lymphatic vessels. Myosarcoma is an 
engrafting of the disease upon a fibroid, and the term adeno- 
sarcoma indicates that glandular tissue has been included within 
the growth. Fibrosarcoma usually exhibits a roundish growth. 
The entire new formation may present a degeneration into 
sarcomatous tissue, so that upon section it exhibits a soft, mar- 
row-like structure, or may be somewhat firm and uniformly 
opaque, with moist or mottled surface. Frequently the tissue 
resembles fish flesh. At other times the myoma has undergone 
sarcomatous change only in parts of its structure, and these 
points of degeneration give the section a striated appearance, in 
which the nodules are distinctly recognized. The sarcomatous 
degeneration is most frequently found in the center of the mass, 
so that it is surrounded by a myomatous crust. Gusserow's 
assertion that the fibrosarcoma continually loses its capsule is of 
no significance, for not every myoma has a capsule. 

Fibrosarcoma can attain an enormous size, forming a tumor 
which reaches beneath the ribs. If the tumor is projected into 
the uterine cavity, it is generally covered by the mucous mem- 
brane which is not penetrated by the disease, and occasionally 
the tumor, thus covered, is extruded into the vagina. The sub- 
mucous tumor mostly springs by a broad base from the wall of 
the uterus, in which no sarcomatous tissue is found. If the sub- 
mucous tumor has attained a large size, disturbances of nutrition 
may have already occurred which lead to suppuration. The 
longer the growth exists, the greater the inclination to destruc- 
tion, especially if it is soft and has grown rapidly. In the sub- 



GENITAL TUMORS. 841 

mucous growth the uterus tends to enlarge, especially when the 
tumor is of the interstitial variety. On the other hand, the 
intraligamentary subserous sarcoma produces an enlargement or 
alteration of the uterus, which should not be overlooked. 

These sarcomata, like the myomata from which they mostly 
project, are but slightly supplied with vessels, though they fre- 
quently have a distinct telangiectatic form. 

Much diversity of opinion exists as to what constituent of the 
wall affords origin for the sarcoma cell. Virchow attributed it 
to the intercellular substance: "Their cells increase by division, 
they consist more and more of round cells, beginning small, later 
larger, with considerable nuclei, as large mucous bodies, while the 
intercellular substance is looser and more spong}^" Kahlden 
believed that sarcomatous degeneration resulted from the imme- 
diate transformation of muscle-cells into roundish cells; their 
poles then became oval or blunted. Whitridge Williams says that 
under rapid increase of the number of cells this section of tissue 
passes into pronounced spindle-celled sarcoma with irritation 
cells. Ricker explains the gro\^^h "naturally by a growing 
through of myoma bundles by the side of the sarcoma tissue." 
Ruge says, "The impression exists, as if the fine, small muscle- 
cells passed over directly into the sarcoma cells." Gessner, from 
extensive investigations, concludes: "The round-cell sarcoma 
continually takes its origin from the connective tissue, and, like- 
wise, the majority of the spindle-cell sarcomata ; but that in all 
probability to the smallest part they lead back to an immediate 
transformation of muscle-cells." 

667. Etiology. — The cause of sarcoma is unknown. Cohn- 
heim's theory that it originates from some congenital defect 
affords no further information. In other parts of the body sar- 
coma is attributed to injury, but the occurrence of rapidly 
developing sarcoma following trauma is no indication that the 
latter is the cause. Injuries during parturition, difficult delivery 
of the placenta, frequent labors, and blows upon the sacrum 
have been assigned as causes for its development. Labor, how- 
ever, does not seem to be a factor, as two-thirds of the cases are 
below the average in child-bearing, and in a great majority there 
is a long interval between the last labor and the development of 
the disease. The cervix is most subject to injury during labor, 
while the body of the organ is more subject to the disease. 

Predisposing factors are: Age. The cases of sarcoma of the 
mucous membrane preponderate between the ages of fifty and 
sixty, although a large number are found between the ages of 
five and twenty; sarcoma of the wall is absent in the young, 
while the maximum number is found between the ages of forty 
and fifty. Trauma, parasitic irritation, syphilis, and the presence 



842 GYNECOLOGY. 

of fibroids are included, but, if factors, the query becomes im- 
portant, Why are the cases not more frequent? Gusserow 
believed that it originated from changes in the fibroid, and Mar- 
tin saw the disease follow the ergot treatment of fibroid in six 
cases. The latter number, however, is too small for a definite 
conclusion. Heredity as a factor is undetermined. Poverty has 
been given as a cause, but Weil has shown that one -fourth of 
the cases of sarcoma of the mucous membrane have occurred in 
the well-to-do. 

668. Symptoms. — Sarcoma, like carcinoma, presents no char- 
acteristic symptoms. The more important indications or signs 
which should awaken suspicion of its existence are hemorrhage, 
discharge, pain, and, in advanced stages, cachexia. In more 
than one-half of the cases bleeding is the first symptom, and 
is rarely absent. It begins by increased menstrual flow, then a 
bloody, watery discharge, which is not sudden, as in fibroma, 
but more or less continuous. It comes from the associated 
endometritis, while a stronger flow is indicative of destruction 
of the new formation. Rupture of vessels and more or less 
severe hemorrhage occur in the diffuse variety, but the polypoid 
form does not readily break down. In the cervical variety the 
disease occurs quite early in life. It has been observed at two 
and one-half years and displays a preference for the young at 
the period of awakening to sexual activity. The earlier symp- 
toms are similar to those of mucous polypus, such as hemorrhage 
and discharge. During sexual activity there is first increased 
menstruation, then irregular discharge of blood, later pain, 
which results from the pressure of the increasing growth upon 
the cervix. The extension of the disease to the parametrium 
causes pressure upon the pelvic nerves and the formation of 
masses which press up the uterus and lift it out of the pelvis. 
The hemorrhage and diffuse discharge result in a high degree of 
anemia, and finally cachexia appears, and the patient ultimately 
perishes from marasmus and the penetration of the disintegrating 
tumor into the abdominal cavity with fatal peritonitis. In the 
frequently recurring sarcoma of the mucous membrane, which 
appears at the climacteric, hemorrhage is the first, and often for 
a long time the only, indication of the disease. The obstruction 
to the uterine discharge will frequently result in the formation 
of a pyometra or hematometra and the development of a tumor, 
which will reach to the ribs. The uterine collection may be bloody 
or mixed with tissue and it often attains an enormous size. Dis- 
charge is the first symptom in about one-fourth of the patients 
and does not cease with the further progress of the disease. It 
begins as a quite abundant, thin, w^atery fluid, which is later 
mixed with blood. Such a discharge continuing for a length of 



GENITAL TUMORS. 843 

time as the only symptom should arouse a suspicion of the 
existence of sarcoma. It is true that discharges of this character 
are not rare as a symptom of submucous fibroids, but its occur- 
rence after the menopause is an almost positive indication of 
sarcoma. In the first stage there is no disagreeable odor beyond 
the stale sweetish smell, but with the destruction of the new 
formation the discharge becomes purulent, sanious, and has a 
foul odor. The carrion-like smell so characteristic of cancer is 
not usually present, because the large collections in the uterus 
are retained by the obstruction, and, owing to the arrangement 
of the vessels, are afforded better nutrition, so that the new 
structures do not so easily break down. The disease generally 
appears in the polypoid form. Sanious discharge occurs when 
the uterus forces the new-growth out, the os is dilated, and the 
diseased mass is extruded into the vagina. The extruded parts 
are to some degree deprived of nutrition, and this results in 
further destruction. The discharge in the vagina has abundant 
opportunity for exposure to infection from saprophytes, which 
accelerate the rapidity of destruction. It is then mixed with 
ulcerative pieces of tissue, which are often thrown off in large 
masses, and these still further disintegrate in the vagina. A 
bloody discharge will follow and pyometra can occur, but this 
never attains the same extent as the hematometra. Pain is 
absent at the beginning of the attack, but is aggravated with 
the increase in the size of the uterus, the persistent pressure in 
the pelvis, and the sensation of fullness in the abdomen. As the 
uterus becomes enlarged, pain is referred to the ilium or to 
the sacrum and radiates down the thighs. The extension of pain 
is due to the involvement of the uterine nerve-endings by the 
new formation. Pain is greatly aggravated when the disease has 
passed beyond the boundaries of the organ and infiltrated the 
pelvic tissues and made pressure upon the large nerve-trunks. In 
the polypoid variety the pain becomes labor-like when the struc- 
ture attains a size which leads the uterus to expel it. Painful 
attacks do not occur at such regular hours as in carcinoma. 
Inversion of the uterus has been caused by the efforts of the 
organ to expel its contents. Vesical symptoms are comparatively 
frequent when the disease is confined to the uterus and are 
manifested by more frequent desire to urinate, pain in evacua- 
tion, and distressing vesical tenesmus. These symptoms are 
more particularly seen in the circumscribed variety and are, con- 
sequently, not the result alone of increased weight. In advanced 
stages constipation is marked from pressure of the infiltrate upon 
the rectum and partly from decreased nutrition. Such patients 
apply for relief from constipation and the pain at stool. The 
infiltration of the uterus can attain to considerable dimensions, 



844 GYNECOLOGY. 

but, unlike carcinoma, shows but little inclination to compress or 
involve the ureter. As the .cervix is rarely involved, vesical 
and rectal fistulae are infrequent. The constant drain will neces- 
sarily affect the general health, and the cachexia is greater than 
in cancer. In sarcoma of the uterine walls, frequently known as 
fibrosarcoma, the great diversity of symptoms depends upon the 
situation of the disease, and makes it impossible to present a 
clinical history, as in other forms of trouble. However, one of 
the first signs is an irregular bleeding, following the menopause, 
in a woman who has had a myoma. The myoma rarely delays 
the climacteric longer than the fifty-fifth year. The continuation 
of the menses at an advanced age or their return after ceasing 
should indicate the probable degeneration of an existing myoma. 
Following the climacteric, the myoma ordinarily ceases to grow 
or decreases in size, while a sarcoma of the uterine wall increases. 
A rapid growth subsequent to the climacteric is with rare ex- 
ceptions an indication of sarcomatous degeneration of a myoma. 
A symptom constant in sarcoma and always absent in myoma 
is a premature and rapid cachexia. From great loss of blood 
the myoma may cause anemia, but the sarcoma causes emaciation. 
When the cachexia occurs without much loss of blood, it indicates 
an unfavorable influence upon the blood composition and forma- 
tion. The cachexia is preceded by a sense of weariness, pain 
in the head, nausea, sleepiness, and universal pain throughout 
the body. Furthermore, there is a sensation of tension in the 
belly without marked increase in the tumor. Difficulty in 
urination without compression is also present, and disturbance 
of nutrition without other assignable cause is quite marked. A 
profuse watery mucous or watery bloody discharge occurs similar 
to that from an ulcerating submucous myoma, except that in 
the latter the growth is not discharged in pieces, but the tumor 
retains its integrity and disintegrates from the surface, while in 
sarcoma large portions of the mass are thrown off or are easily 
broken off by the hand. Pain is produced when the disease 
breaks through the walls of the uterus and undergoes great 
extension. Labor-like pains are caused if the uterus attempts 
to discharge its contents. Sarcoma occurs in but a small per- 
centage of cases of myoma, yet sufficiently often to justify it 
being reckoned as a factor. While the possibility of this de- 
generation is no indication that every patient suffering from 
myoma should be subjected to an operation, still it is a warning 
which should awaken suspicion when adverse symptoms develop 
in the tissue thus affected. Paget described a peculiar form of 
this disease under the designation of recurrent fibroids. Whether 
in these cases successive mucous fibroids were discharged or the 
condition was sarcoma from the beginning only the microscope 



GENITAL TU.MORS. 845 

could have determined. Schroder made a vaginal extirpation in 
a patient from whom he had removed seven successive polypi, 
the last three of which were sarcomatous. The removal of the 
sarcomatous growth long years after previous removal does not 
prove that the former was malignant. The possibility of such 
changed tumors occurring should be decided by more fre- 
quent examinations with the microscope, in order that extirpa- 
tion may be promptly resorted to when malignancy is demon- 
strated. 

It is asserted that metastasis is late in its occurrence in 
fibrosarcoma. This assertion is correct only as to the length of 
time symptoms exist prior to such manifestations, but does not 
indicate the long existence of sarcoma. 

669. Duration. — The duration of the disease in sarcoma of 
the cervix is about the same as that of cancer of the part — 
namely, about one and one-half years. It is more difficult to 
fix the term of the disease in the variety involving the uterine 
mucous membrane, as the earlier symptoms do not come under 
the observation of the physician. Cases have been reported as 
having survived several years ; the average duration, however, is 
about two years. The polypus is slower in its progress, probably 
dependent upon a slighter inclination of this form to invade the 
muscle wall. Metastases occur in about one-fourth the cases and 
affect any tissue in the body. The structures most frequently 
affected are the lungs, peritoneum, lymph-glands, and intestines. 
In the cervical variety it is likely to extend to the vagina, where 
the involvement is superficial and does not interfere with cure 
if extirpation of the uterus is performed, provided the operation 
is done early. To afford hope of recovery the diagnosis must be 
made early, and not after the recurrence of the disease following 
curetment or amputation of the cervix has demonstrated its 
malignant character. The polypoid growths from the cervix 
should be recognized by their peculiar appearance, and the micro- 
scopic examination of the cureted scrapings should render the 
diagnosis certain. The reformation of the polypus should lead to 
the suspicion of malignancy, and a careful microscopic examina- 
tion should be made to determine its true character. In the 
fibrosarcoma it is still more difficult to fix the duration of the 
disease, as we have no means of knowing when the degeneration 
of the fibroid begins. Cases have been reported in which tumors 
existed for ten years. These are probably cases in which the 
myoma has existed for a long period and only in the later years 
become malignant. IMetastases in this form appear late, follow 
the course of the blood-vessels, and, like the other forms of the 
disease, involve the lungs, pleura, liver, rectum, omentum, and 
kidneys. Fibrosarcoma is frequently regarded as a compara- 



846 GYNECOLOGY. 

tively benign tumor, because it remains proportionately limited 
to the uterine cavity, but this is incorrect, for this property is 
common to mucous membrane sarcoma and cancer of the body 
of the uterus as well. If metastasis is any criterion as to malig- 
nancy, we must regard parenchymatous sarcoma as more malig- 
nant than the mucous, for in the latter metastases occur in 
only one-fourth of the cases, while in the former but one-fourth 
escape. Although it is impossible to fix the duration of life, it 
would seem to be longer than in the other forms of malignant 
disease. Its progress is attended with the same symptoms as in 
other forms of malignancy. Its termination is usually death 
from exhaustion, bleeding, and discharge, and by the further 
extension of the disease into the various parts of the body. 
Sepsis plays a less important part than in the mucous variety, 
and ulceration does not appear so frequently, and, when present, 
by the evacuation of the ulcerating mass does not usually cause 
general symptoms, though a purulent peritonitis has been fre- 
quently reported as a cause of death. 

670. Diagnosis. — Sarcoma of the mucous membrane can be 
accurately determined only by microscopic examination. Other 
means will be sufficient to render certain the existence of ma- 
lignant disease, but the variety is determined only by the micro- 
scope. Neither the condition nor symptoms offer anything char- 
acteristic of sarcoma, while a majority of the diseases of the 
uterus afford similar symptoms. 

An elderly woman with a large uterus, who suffers from a 
profuse watery discharge mixed with blood, should be suspected 
of having sarcoma. Submucous myoma sometimes causes a 
similar discharge, but the uterus is greatly enlarged, and it does 
not occur for the first time in advanced age, and is always accom- 
panied by bleeding. 

Senile endometritis may cause a profuse discharge, but the 
discharge is purulent, and generally has a disagreeable odor. 
The organ presents the characteristic changes of old age, and is 
not large. 

A second suspicious sign is vesical tenesmus, which should 
be regarded as an indication of malignant disease when no other 
cause exists. 

Sarcoma of the uterine body is naturally difficult to diagnose. 
It can be completely covered by the cervix and the vaginal 
portion, and when a large cauliflower-like mass projects from the 
cervix, it can be either sarcoma or cancer, and the microscope 
only can determine which. In the differential diagnosis there 
are a variety of diseases which must make the diagnosis only 
probable. 

The uterine body is always enlarged, but does not differ 



GENITAL TUMORS. 



847 



essentially from the enlargement of chronic metritis, myoma, 
and carcinoma. The sarcomatous uterus is not so hard as the 
myomatous organ. In malignant disease the very much en- 
larged organ indicates sarcoma, but the carcinoma may be super- 
imposed upon a myomatous uterus. In the latter the form of 
the uterus is irregular. 

Fungous endometritis, a mucous polypus, and submucous fi- 
broid may require the use of the microscope to differentiate them. 




Fig. 536. — Fibroma Undergoing Sarcomatous Change. 



Positive proof of malignant disease is not obtainable by the 
touch. A sensation of softness is common to mucous polypi, 
submucous myoma, and mucous membrane sarcoma. Pieces of 
the latter can be broken off with the finger, as also from other 
growths when ulcerating. Touch with the finger is not always 
free from danger. It will be safer to employ the microscope upon 
the scrapings obtained by curetment. 

The inexperienced investigator may be confused by the resem- 
blance between sarcoma and interstitial endometritis, with more 



848 GYNECOLOGY. 

or less destruction of the glands. In doubtful cases examine all 
the parts removed before making the decision that malignant 
disease does not exist, and, if then in doubt, keep the patient 
under close observation. If she continues to bleed, make a 
second curetment, and again examine the scrapings. 

The abundance and variety of the cells in a specimen are of 
significance in the diagnosis of sarcoma. In round-cell sarcoma 
the cells are round and thick, and exceed in size those of the 
intermediate gland tissue, between which are found irregular 
cells. Kellar places particular stress upon the fact that the indi- 
vidual nucleus is differently formed and varies in the way it 
accepts the color stain, so that the smaller nuclei are always 
better colored than the larger. When the glands are absent, the 
cells are usually pressed together and the epithelium is flattened. 
If the glands have largely decreased in interstitial endometritis, 
there are distinctive traces of connective-tissue formation in the 
intervening structure, which is penetrated in all directions by the 
migration of connective-tissue cells. They differ from spindle 
cells in that the long axis is drawn out at the ends, and the long 
axis of the nucleus does not fill out the body, while in the spindle- 
cell sarcoma the cells are smaller, plumper, only rarely with 
pointed ends, and the nucleus almost fills out the body. 

The distribution of the vessels is also very significant. In 
benign changes of the endometrium the blood-vessels are few and 
present distinctive walls, while in sarcoma they are much more 
abundant, and appear in immediate relation to the surrounding 
tissue of the growth. Amann asserts that the recognition of 
abundant nuclear division can be employed for the diagnosis of 
sarcoma. 

In the differential diagnosis of subinvolution of the decidua 
and incomplete abortion the clinical history is of advantage ; but 
if long-continued, irregular menstruation is followed by severe 
hemorrhage, perhaps an offensive discharge, while the uterus 
remains large and not especially hard, confusion with sarcoma is 
possible, which will require the microscope for confirmation, and 
then not always with certainty. The individual decidual cells 
closely resemble those of sarcoma of the mucous membrane. The 
retained tissue glands will present the alterations of pregnancy in 
their epithelium to such a degree that the error is easily avoided. 
The difficulty will be greater when a retrogression of the decidua 
has occurred, for the uniform structure of the decidua is de- 
stroyed. In single sections, however, individual islands of the 
decidual structure will be found, while other sections will show a 
great irregularity in the cells. The size of the cells is quite 
variable ; frequently the decidual cells show a pronounced spindle 
shape, and penetration of the tissues by round cells exists, so 



GENITAL TUMORS. 849 

that a structure is formed which is extraordinarily Hke a sarcoma. 
Differentiation is easily accomplished in such cases by demon- 
strating the chorionic villi. If we find the decidual cells by curet- 
ment of a woman who has had an abortion months before, we 
will also find the ^chorionic villi present, for the decidual cells 
are not otherwise so long retained. In the absence of the chori- 
onic villi the diagnosis is fixed by finding, near the large decidual 
cells, sections of tissue which show the unaltered mucous mem- 
brane with retained glands or with the recognizable alterations 
of interstitial endometritis. 

Tuberculosis of the endometrium, by the premature loss of the 
glands, through the appearance of numerous round cells in the 
tissue and the occurrence of irritation cells, causes confusion with 
sarcoma. The clinical history, the demonstration of caseation, 
the peculiar irritation cells of tuberculosis, and the rarely demon- 
strated tubercle bacilli will protect against confusion. 

Carcinoma of the Uterine Body. — There are certain forms of 
cancer which can not be distinguished microscopically from sar- 
coma. We can, however, determine that malignancy is present. 

As in the mucous sarcoma, the diagnosis is made only by 
microscopic examination of the discharged or removed pieces of 
the growth. Greater difficulties are experienced in securing the 
material for study than in the latter. A suspicion that fibro- 
sarcoma exists should be awakened : 

First, if a myomatous tumor does not cease to grow after 
the menopause. Rapid growth does not always follow sarco- 
matous degeneration. 

Second, if a woman with a myomatous tumor commences to 
bleed after the menopause. In rare cases this may occur in ad- 
vanced age from mucous polypi, but the association of a profuse 
watery discharge should be held to be very suspicious of sarcoma. 

Third, if with a myomatous tumor cachexia occurs. Through 
excessive bleeding myoma causes anemia, but never cachexia. 

Fourth, if a myomatous tumor occasions symptoms which are 
explainable neither by the size nor the sityiation of the tumor. 

Fifth, if ascites complicates the tumor. The possibility of its 
being caused by other conditions must be excluded. Ascites 
occurs from penetration of the peritoneum by the disease, and 
may follow a subserous tumor which has become sarcomatous. 

Sixth, if a myoma which was previously hard grows rapidly 
and becomes soft and swollen. 

Seventh, if after the removal of a fibrous polypus another 
follows. 

671. Recurrence. — The tendency of the disease to return even 
seems greater in the fibrosarcoma than in the mucous growth. 
It is probable that the explanation of the greater frequency of 

54 



850 GYNECOLOGY. 

the occurrence in the former is due to the early recognition and 
more prompt treatment of the latter. When a case of mixed 
sarcoma remains a year free from recurrence it may be con- 
sidered as cured, but not so the fibrosarcoma, for it has been 
known to return at a much later date. The great difficulty in 
the treatment of this, as in all malignant disease, is the impossi- 
bility of determining the diagnosis before the disease has ex- 
tended beyond the point at which it can be surely removed. 
Our results must continue bad until both patient and physician 
have learned to realize that uterine hemorrhage is a symptom 
which demands prompt and thorough investigation. When the 
disease has so extended that a radical procediire is no longer 
indicated, we direct our efforts to the arrest of hemorrhage, the 
decrease of discharge, and the improvement of the general condi- 
tion of the patient. 

Chorio -epithelioma. — This is a condition which it will often 
be possible to determine by touch through an accessible cervical 
canal. But little satisfaction will be secured by examination of 
the tissue removed by the curet, as it will consist mostly of blood- 
clot containing a few pieces of necrotic tissue. 

672. Treatment. — Whenever possible, the uterus should be 
extirpated. No other measures are worthy of consideration, but 
the case must come under observation sufficiently early to admit 
of the extirpation of the organ within the limits of healthy tissue. 

Operation is contraindicated when the disease has so broken 
down the system of the patient that she will be unable to en- 
dure the ordeal of a radical procedure. It is also contrain- 
dicated when the growth is no longer confined to the uterus. 
The existence of metastases and the extension of the disease 
beyond the confines of the uterus would render operation of no 
avail. This assertion does not apply to extension upon the 
vagina if the disease can be removed. The existence of 
ascites must not influence against the procedure unless the 
involvement of the retroperitoneal glands can be demonstrated. 
The removal of the entire uterus, even in slight cases, is indicated, 
because it affords greater immunity against return than any 
partial operation. When the size of the uterus permits, the 
operation should be performed by the vagina. This can usually 
be done in .cases of mucous sarcoma, as the organ is rarely of 
large size. The fibrosarcoma may often be scraped out and 
the size of the organ may be reduced by the administration of 
ergot for a few days, and then the vaginal operation may be 
performed. It is unwise to subject the healthy tissues to in- 
fection by cutting up the tumor to reduce its size. 

673. Treatment Following Operations for Malignant Dis- 
ease. — The after-treatment of such patients will have been greatly 



GENITAL TUMORS. 851 

simplified by judicious care during and preceding the operation. 
This care includes thorough sweeping out of the intestinal canal 
with saline purges, the administration of intestinal antiseptics, 
as salol or the sulphocarbolates, a restricted diet from which 
milk has been excluded, the exclusion of every possible means of 
infection by cleansing the patient and during the operative pro- 
cedure, the employment of measures to sustain the circulation in 
prolonged procedures. Immediately following the operation 
she should be under the care of a conscientious nurse, who will 
see that she is kept properly covered in a well-ventilated room. 
Where necessary, the bodily temperature should be maintained 
by artificial means, such as hot blankets and hot -water bottles. 
Do not allow this to drift into a routine procedure to be employed 
regardless of conditions, as, for example, after a difficult operation, 
upon a very hot day, following the patient to her room, I found 
her covered with blankets and surrounded with hot bottles ; upon 
taking her temperature it was found to be 1 04° F. Obviously this 
patient was getting the opposite of what she should have had. 
The patient, unless very feeble, should not be confined to one 
position, but should be permitted to move from side to side. The 
pulse, temperature, and general appearance of the patient should 
be carefully watched for danger signals. Where the patient is 
uncomfortable and unable to evacuate the urine, it may be drawn 
by catheter, but catheterization should be avoided, where possible, 
and need not be employed under sixteen hours unless the patient 
complains of distress. For the general principles of after-treat- 
ment the reader is referred to sections 206-220, as only details 
especially referable to operations for malignant disease will be 
here discussed. 

If the abdominal wound is closed, the vaginal tampon of 
gauze may be permitted to remain for from six to nine days. 
In the third week the patient is permitted to arise, and in the 
fourth to go about the house. When clamps are used instead of 
ligatures, the weight and dragging of these instruments increase 
the pain. The distress is aggravated by every movement, and 
frequently morphin may be required to make it endurable. The 
difficulty is often increased as early as the day after the opera- 
tion by an accumulation of flatus. In the majority of cases the 
difficulty appears later, and is relieved only after prolonged rec- 
tal irrigation. The meteorism, increased abdominal sensibility, 
enhanced rapidity of pulse, and elevation of temperature pro- 
duce anxiety, which is aggravated by prolonged vomiting 
and other signs of ileus. A number of cases are reported of 
a fatal result from kinking of the intestine. The continuation 
of such symptoms should lead to removal of the gauze, for 
fear that it is causing the obstruction. This is done with the 



852 GYNECOLOGY. 

recognition of the fact that the adhesions are not firm, and 
that trouble can arise from its premature removal. The cavity 
should be tamponed lightly. In the removal of the gauze care 
must be exercised that a knuckle of intestine is not drawn into 
the vagina. Such an accident occurred in one of my patients, 
where the interne withdrew the gauze and found that there 
was a large coil of intestine in the vagina, which he could not 
replace. I placed the patient upon her side, with the hips ele- 
vated, and had no difficulty in replacing the intestine, which 
was kept in place by a gauze tampon. As to how long the 
gauze shall remain, operators differ — from the one or two days 
of Doyen to the ten days of Zweifel. The latter prefers the 
longer period because the earlier removal of the gauze breaks 
up the adhesions and draws down the intestines; at the later 
period the gauze has become loosened and the intestinal ad- 
hesions are so firm that they are undisturbed. 

The clamps are generally removed at the end of forty-eight 
hours. Landau and Seligman remove them on the second day. 
I have had several cases of quite severe hemorrhage after re- 
moval at the end of forty-eight hours — hemorrhage which 
is difficult to control. The occurrence of hemorrhage requires 
resort to exposure of the cavity by retractors, and the ligament 
must be followed up and the bleeding vessels again secured 
with forceps. 

Another objection to the use of clamps is the danger of 
injury to the ureter and the bladder, but this is due to want 
of care in pushing away these organs, and is just as likely to 
occur from careless use of the ligature. Injuries of the rectum 
are also reported, but are less excusable than those of the urinary 
apparatus. Among the causes of fatal result sepsis is the most 
frequent. 

FALLOPIAN TUBES. 

674. Tumors (Benign). — Tumors or growths of the tubes 
are exceedingly rare, except as a result of inflammatory changes. 

675. Fibroma or myoma is infrequent and of small size. It 
develops from the muscular tissue of the tube, and may grow 
inward or become subperitoneal, but rarely obstructs the lumen 
of the tube. Inflammatory and tuberculous changes have 
been mistaken for myoma, particularly the condition known 
as salpingitis nodosa. Under the name of adenomyoma or 
cystadenoma Recklinghausen describes a peculiar form of 
myoma which occurs only in the uterus and tube. It is char- 
acterized by the usual constituents of the fibroid, which include 
glandular structure. In the tube he attributes it to some re- 
mains of the primordial structure — the Wolffian body. 



GENITAL TUMORS. 853 

676. Fibrocyst. — A unique new formation is described by 
Sanger-Barth, which consists of three tumors collected from 
a conglomeration of various large cysts and firm tumors that 
were in part pedunculated from the fimbria of an otherwise 
healthy tube. Microscopically, the wall of the cyst consisted 
of fibrous connective tissue with smooth muscle-fiber, and, 
within, a nest of embryonic tissue. Its surface was covered 
with ciliated epithelium, and the contents of the cyst were 
detritus. The principal mass of firm tissue partly consisted 
of gelatinous myxomatous and partly of loose cell tissue. The 
products greatly resembled a teratoma. 

677. Enchondromata are small, semitransparent, cartilagin- 
ous masses, which are occasionally situated upon the ends of 
the fimbria. 

678. Dermoid of the tube is exceedingly rare. Ritchie de- 
scribes a plum-sized bone removed from a dermoid of the 
tube. Pozzi, in a recent edition of his work, presents a diagram 
of a dermoid cyst removed from the tubal wall, which was ad- 
herent to the ovary. It had developed within the tube and 
ulcerated through the overlying wall. 

679. Cysts of small size are frequent, though their true 
cystic character is denied. The large irregular bullse so common 
in association with fibroid growths are said to be dilated lymph- 
spaces. Cysts varying from the size of a pea to that of a walnut 
are found in all the walls of the tube, but most frequently be- 
neath the peritoneum. Cysts within the tube are not infre- 
quently the result of inflammatory changes by which the ad- 
joining folds of the mucous membrane become adherent. Cysts 
of the tubal fimbria become pedunculated and resemble the 
hydatid of Morgagni, which is by some regarded as a cyst. 
The cysts contain clear serum, colloid masses, or chalky bodies. 
Sanger divides these cysts into: 

1. Serous cysts, which arise by the accumulation of serous 
fluid between the lamellae of the new mucous membrane. They 
can attain the size of a child's head, and may be either single 
or double. 

2. Lymphangiectasis and lymphangiectatic cysts in three 
forms: (a) As small vesicles upon tube and ligament, identical 
with those of older authors; (b) winding, ramifying tubes with 
constrictions and cystic distentions ; (c) lymphangiectatic cysts — 
large, tough-walled, isolated cysts in the tubal serous cover- 
ing or the mesosalpinx. The two latter occur especially with 
uterine myoma. 

3. The hydatid of Morgagni, regarded as a physiologic cyst 
of the end of a tubal fimbria. 

Inflammatory cysts of the tubes — known, from the character 



854 GYNECOLOGY. 

of their contents, as hydrosalpinx, pyosalpinx, and hemato- 
salpinx — have been discussed under inflammation. (Section 

452.) 

680. Polypus is a rarely recognized growth. Lewers re- 
ports a case in which, upon the inner surface of each dilated 
tube, were numerous growths, varying in size from a pin's 
head to a pea. Amann speaks of a growth of the mucous mem- 
brane consisting of connective tissue covered with enormously 
folded cylindric epithelium. Rokitansky and Klob describe 
connective-tissue growths of the fimbriae. 

681. Papillomata, denominated by Sutton as adenomata, 
are allied to the condylomata, or warts, found upon the vulva. 
The villus consists mainly of epithelium. Sanger has collected 
six cases, and divides them into two forms: (i) Simple cystic; 
(2) hydropic. 

The simple cystic is an indefinite soft growth from the mucous 




Fig- 537- — Papilloma of the Fallopian Tube. 

membrane, of a cauliflower-like appearance (Fig. 537), and its 
villous structure may fill out the tube and distend it into a 
considerable sized tumor. 

In the second form (cystic and vesicular papillomata) the 
tubal end becomes closed and the villi are so swollen as to give 
the appearance of a cystic mole. This form differs from the 
first in the greater size of the cavity, from the inner surface of 
which spring the papillary masses. Doran and Sutton have 
attributed the occurrence of papillomata to previous gonorrhea, 
but with such a cause they should occur more frequently. They 
are difficult to differentiate from sarcoma and cancer. Their 
benignity, however, is proved by the absence of any tendency 
of their epithelium to atypic gro^^th, and there are no metastases. 



GENITAL TUMORS. 855 

682. Malignant Tumors. — Carcinoma of the tube may be 
either primary or secondary, though the latter is the more 
frequent. Secondary involvement of the tubes from cancer 
of either the ovaries or the uterus is comparatively late, as we 
not infrequently find the ovary forming a large tumor from 
cancer or sarcoma without any involvement of the tube, Doran 
divides primary cancer of the tube into two forms: 

1. When the cancer develops in the mucous membrane 
of a normally formed tube. 

2. When it forms in a malformed tube bearing a cyst the 
wall of which becomes infected. 

In the first form its situation shows its origin in the papil- 
lary structure — whether from degeneration of papilloma, as 
believed by Doran, or directly from the tubal mucous mem- 
brane, as asserted by Sanger-Barth, remains to be determined. 
The occurrence of the disease in the middle and external por- 
tions of the tube indicates that it is a sequel of inflammatory 
trouble. 

In the second form the disease develops in a cyst of the 
ostium. Doran describes a specimen in which the end of the 
right tube was dilated for an inch and a half, was very tortuous, 
and formed a tumor an inch in diameter at its widest part. 
In its wall was a solid deposit, over a quarter of an inch in thick- 
ness. At its outer part it communicated with a thin-walled 
cyst, situated in the anterior part of the broad ligament, lifted 
up its anterior fold, and raised the serous coat of the uterus. 
The cyst was about six inches in diameter, and its interior 
contained a thick deposit which appeared encephaloid in char- 
acter. Under the microscope the stroma was scanty, with wide 
alveoli containing great masses of cubic epithelial cells, as in 
encephaloid cancer. 

Amann is inclined to believe that cancer of the tube will 
prove to have developed through metastases from the uterus. 
The disease is generally confined to one tube. The recognition 
of its existence is necessarily difficult. When, after previous 
pelvic inflammation, a patient who has reached her forty-fifth 
year shows a sudden or steady growth of subjective and ob- 
jective symptoms, cancer, says Doran, may be suspected, and 
watery or sanious discharges greatly increase the- suspicion of 
malignancy. 

Treatment should consist in the prompt removal of all 
infected structures. 

683. Sarcoma of the ovary is frequent; of the tube, very 
rare. Occasionally, the sarcomatous nodules are found scattered 
over the peritoneal surface of the tube, but the disease more 
frequently passes from the ovary to the omentum. Kahlden 



856 GYNECOLOGY. 

reports a case in a woman of fifty-one years, in which the tube 
formed a sausage-shaped mass filled with soft, cauliflower-like 
material. Under the microscope it showed various degenera- 
tions, such as round-cell and spindle-cell sarcoma, and a papil- 
lary structure wanting in connective tissue. These forma- 
tions were found to arise from the endothelium of the lymph- 
vessels, which was increased several layers. As important 
constituents could be shown irritation cells similar to those 
in sarcoma. 

684. Chorio -epithelioma Malignum. — Just as malignant de- 
generation can occur in a portion of placenta or chorion which 
is retained in the uterus and produce a large tumor and subse- 
quent metastatic deposits in the abdominal and thoracic viscera, 
a similar malignant change may follow an ectopic gestation 
in the tubal sac. Sanger advances this as an additional argu- 
ment for active interference in such cases, and for the extir- 
pation of tubal moles and of the appendages when tubal abor- 
tion has occurred. 

BROAD LIGAMENTS. 

'^1 685. Cysts of the broad ligament varying in size from a 
pea to a pigeon's egg are frequent, and generally of but little 
clinical interest. They may be situated upon the surface of 




Fig- 538- — Broad Ligament Cyst. 
T. Fallopian Tube. P. Parovarium. O. Ovary. 

the ligament or may lie deeply within its folds. Their walls are 
thin and the contents of the cyst consist of a watery or pale 
colored fluid. Superficial cysts are of undetermined origin, 
while the deeper growths are attributed to changes in the par- 



GENITAL TUMORS. 



857 



ovarium. I recently removed a multilocular cyst from the 
anterior surface of the broad Hgament by opening the over- 
lying peritoneum and enucleating the cyst. The ovary was 
not affected and was left undisturbed. These cysts are fre- 
quently pedunculated, but rarely attain to any great size. 
They are generally called microcysts, and are often developed 
in the structure or suspended from the organ of Rosenmuller. 
Only those which develop from the vertical tubes of the parova- 
rium have ciliated epithelium and are liable to form papillary 
growths subsequently. 

Parovarian Cysts. — (Section 702.) 

686. Echinococcus cysts are rare, except in certain districts, 
notably Iceland and ^Mecklenburg. In the majority of cases they 
primarily occur in the pelvic connective tissue, and always near the 




Fig- 5o9-— Rroad Ligam. 



.th Torsion of Its Pedicle, 



intestine. In rare instances the ovary proves to be the primary 
seat of the disease. The Avandering of the parasite causes a chronic 
inflammation, characterized by round, elastic tumors situated 
near the rectum, which are slightly movable, but not painful. 
Bimanual palpation reveals that they are not connected with the 
uterus or ovaries. A positive diagnosis is to be determined only 
by a careful examination of the fluid obtained from the cysts, 
either by spontaneous rupture or by pimcture. The danger of in- 
fection from it is so great that the certain determination of 
the disorder will not compensate for the increased peril induced 
by the puncture. 

Treatment. — The proper plan of treatment consists, when 
possible, in the removal of the sac. If we are unable to scoop 
out the cvst, then it should be fastened to the abdominal wall 



858 GYNECOLOGY. 

and drained. Pozzi advocates, when we have had to open 
the peritoneal cavity, that the opening over the cyst should 
be packed with iodoform gauze for from twenty-four to forty- 
eight hours, until adhesions have formed, before the cyst is 
opened, when it can be done without danger of infecting the 
peritoneal cavity. If the tumor is situated low^ in the pelvis, 
a vaginal incision should be preferred. The sac cavit}^ should 
be emptied and packed with gauze. 

687. Parovarian Varicocele. — Phleboliths. — A varicose dila- 
tation of the veins of the pelvis is common, and frequently, 
according to Klob, results in the formation of phleboliths. Their 
frequent occurrence is attributed to the unusual existence of 
valves in the veins of the broad ligament. These masses attain 
the size of a pea or bean, and occasionally cause inflammation 
and thrombus formation. When situated so that they can be 
palpated through the vagina, they are often mistaken for ureteral 
calculi. 

688. Lipomata. — Small collections of fat are not infrequently 
found in the mesosalpinx of the broad ligament near the under 
surface of the tube. They can attain the size of a bean, oc- 
casionally the size of a walnut. 

689. Fibroma. — As the same muscular structure is found in 
the broad ligament as in the uterus, it is not surprising that 
fibroids should occasionally be found in the ligament independent 
of the uterus and its structure. Such growths may spring 
from the round ligament or are found in the broad ligament. 
The latter have been considered as aberrant uterine fibroids 
which have become separated from their first attachment. 
Sanger found these growths most frequently upon the right 
side. They may be situated intraperitoneally, in the fold 
of the groin, or in the labium ma jus. The mass may have a 
pedicle or may be sessile. It does not attain a large size, is 
quite movable, and is not painful. The condition ma}^ be 
confounded with fatty hernia, an epiplocele, or an ovarian 
hernia. The fatty hernia is frequently reducible, painful to 
the touch, quite soft, and ill defined. The irreducible epiplocele 
becomes like a fibroid, but has a cord stretched behind the 
abdominal wall. In an ovarian hernia the tumor retains the 
shape of the organ, is exceedingly sensitive, and increases at 
each menstrual period, while the uterus is displaced to one 
side. The treatment is extirpation. 

690. Malignant Growths. — Carcinoma and sarcoma of the 
broad ligaments are usually the result of extension of the dis- 
ease from the uterus or ovaries. The rectum, the bladder, or 
the retroperitoneal glands may be the source of the infection. 



OVARIAN TUMORS. 859 



OVARIAN TUMORS. 

691. Characteristics. — The tumors of the ovaries differ from 
the neoplasms of the other portions of the genital tract in their 
greater propensity to malignant degeneration, often rendering 
it difficult to determine whether an individual growth is malig- 
nant or benign. For this reason we will depart from the cus- 
tom we have previously followed and discuss the two classes 
of tumors together. 

692. Classification. — The tumors of the ovary are divided: 

{Simple. 
Proliferating. 
Dermoid, 

^™^^^^>' ( r Fibromata. 

/ e 1-j I Sarcomata. 
^^°^^^ Carcinomata. 

I Endotheliomata. 
f Simple. 

Pathologically J Proliferating. 

I Dermoid. 
L Parovarian. 

According to size J Small. 

1 Large. 

Cysts may originate in any part of the tubo-ovarian struc- 
ture, as the cortical, medullary, or parenchymatous portions 
of the ovary; in the structure between the tube and ovary 
known as the Rosenmuller organ or parovarian structures; 
and in the hydatid of Morgagni, the extremity of the canal 
of Miiller. We have already spoken of cysts which develop 
in the folds of the broad ligament and are recognized as broad 
ligament cysts. Cystic growths may become of almost un- 
limited size, larger than any other growth of the body, and 
occasionally the body may seem but an appendage of the tumor. 
These growths repeatedly reach a weight of loo pounds. 
Maritan reported an ovarian cyst weighing 200 pounds removed 
from a woman who previously weighed 290. (Fig. 505.) Her 
girth measure was ninety inches. Bullitt removed a tumor 
whose sac and contents w^eighed 245 pounds, and Spohn, of Texas, 
one of 3 28 pounds with recovery of the patient. 

The solid tumors are much less frequent than the cystic and 
closely retain the shape of the ovary. The cystic are irregularly 
spheric — the more spheric, the larger they become. As a rule, 
the surface is a bluish- white, greenish, brownish, yellow, or 
a glistening white. Secondary developments may occur in the 
wall, giving it an irregular shape, or it may consist of a large 
number of small • cysts, which give the impression of a solid 
tumor. 

Cysts are still further divided into unilocular or single cysts, 



860 



GYNECOLOGY. 



and multilocular, where the sac is composed of a number of 
cavities or smaller cysts. Careful examination of a unilocular 
cyst will not infrequently show smaller cysts within its walls. 
.^The contents of the various tumors greatly differ; indeed, 
the different cysts in the same tumor show radically different 
contents. In the unilocular tumors the contents are usually 
clear and limpid; in the multilocular, thick, viscid, and glue- 




Fig. 540. — Large Ovarian Tumor. 



like in some, clear and limpid in others, while, from various 
causes, there may be discoloration by an admixture of blood, 
pus, or fat. 

The broad ligament cysts are generally unilocular and con- 
tain a clear fluid; those which originate in the hilum are papil- 
lary; and those from the parenchymatous structure of the 
ovary, glandular. 



OVARIAN TUMORS. 861 



Small Cysts. — The small cysts comprise : 

Small residual cysts. 
Follicular cysts. 
Cysts of the corpus luteum. 
Tubo-ovarian cysts. 

The large cysts are: 

Glandular proliferous. 
Papillary proliferous. 
Dermoid. 

r Hyaline. 
Parovarian < Papillary. 

( Dermoid. 

693. Small residual cysts are growths which develop in 
the structure between the tube and ovary, known as the par- 
ovarian structure, or the organ of Rosenmiiller. Those which 
develop in the vertical tubes have ciliated epithelium, and may 




Fig. 541. — Small Residual Cysts. 

subsequently develop into papillary growths. They may be- 
come detached from the ligament and hang from the perito- 
neal surface by a slender pedicle. It is possible that from these 
cysts may originate large cysts filled with either fluid or papil- 
lary contents. 

Attached to the fimbriated end of the tube is generally 
found a small cyst, varying in size from a pea to a cherry, known 
as the hydatid of Morgagni, which, from its almost continuous 
presence, is regarded as a physiologic cyst. This hydatid is 
the termination of the duct of Mtiller, It is transparent, has 
a thin wall, and has a pedicle often a full inch in length. Doran 
describes a supra tubal cyst 'of similar size, appearance, and 
structure, w^hich he supposes to be a microcyst of the broad 
ligament in this anomalous position. 



862 



GYNECOLOGY 



694. Simple or Follicular Cysts. — Hydrops Folliculorum. — 

These cysts are unilocular dilated follicles, generally multiple 
and small. In an ovary that has not attained to twice its 
normal size fifteen to twenty of these cysts may be found. 
When small, the ovary is but slightly enlarged and the follicle 
projects upon the surface or lies embedded in the stroma. These 
cysts were long considered the sole source of large ovarian 
cysts, but it is only in rare instances that they attain the size 
of a fist, occasionally of a man's head. The contents of the 




Fig. 542. — Cyst of the Corpus Luteum. 



cyst are generally clear, but may be blood-stained, and have 
a specific gravity of from 1005 to 1020. The cyst- wall is a 
transparent, thin membrane of a light gray color, covered with 
columnar epithelium. The cysts may be few and the stroma 
excessive, or the former may be very numerous and the latter 
scanty. When the latter condition is present, the ovary is 
frequently converted into a mass of delicate cysts. It is not 
unusual to find an ovary otherwise healthy containing a uni- 



OVARIAN TUMORS. 863 

locular cyst the size of a hen's egg. The disease is generally 
bilateral. 

Etiology. — These cysts, even when large, are regarded as 
unruptured and dilated Graafian follicles, because of the grada- 
tions observed between them and the smaller cysts. In the 
smaller ones ovula may be detected, which have been destroyed 
or have escaped observation in the larger. Failure to rup- 
ture and increase of the fluid contents produce a dropsy of the 
follicle. The normal rupture may be prevented by undue 
thickness or toughness of the walls, the result of inflammation; 
by deposits of exudation over the surface of the ovary; or by 
the deep situation of the developing follicle; or failure may 
be the result of too slight congestion, which, though increasing 
the secretion, is too gradual to produce rupture. Such cysts 
have preceded menstruation, being occasionally found in the 




I^i&- 543' — Tubo-ovarian Cysts. 

fetal ovary. These cysts rarely give rise to symptoms, as men- 
struation, ovulation, and pregnancy continue. 

695. Cysts of the Corpus Luteum. — These are unilocular 
cysts the size of a pigeon's egg, occasionally as large as an apple. 
They were first described by Rokitansky, who believed that 
only the corpus luteum of pregnancy could be thus transformed, 
but such cysts have been found in nullipara. (Fig. 542.) The 
cyst -wall is comparatively thick, lined by a yellow, apparently 
folded membrane, in which microscopic examination shows 
the bud-like papillae characteristic of the corpus luteum. The 
recognition of this structure prevents their confusion with 
follicular cysts, or even with suppurative ovaritis. 

696. Tubo-ovarian Cysts. — An ovarian cyst in contact with 
a distended tube not infrequently results in the formation of 
a tubo-ovarian cyst. (Fig. 543.) The tubal inflammation 
early causes the formation of extensive adhesions fixing the 



864 



GYNECOLOGY. 




J^-. 



tubal ostium to the ovary. The increasing pressure of the 
accumulating fluid gradually absorbs the thin septum until 
the two sacs form one cavity, the smaller portion of which is 
usually formed by the tube. It does not generally attain a 
large size. The uterine end of the tube may remain permeable, 
and, as the fluid increases, permits the excess to drain through 

the uterus, forming a 
condition known as pro- 
fluent tubo-ovarian hy- 
drops. It resembles the 
condition engendered in 
hydrosalpinx, known as 
hydrops tuhcB profluens. 
The open tube acts as a 
safety-valve, preventing 
the increase and over- 
distention of the cyst, 
frequently leading to its 
complete collapse after 
every evacuation. 

697. Glandular Pro- 
liferating Cyst. — This 
class of cysts comprises 
the great majority of 
ovarian tumors, and 
they vary from the size 
of an egg to that of a 
tumor weighing over 
two hundred pounds, 
which may fill up the 
entire abdomen and en- 
croach upon the thor- 
acic viscera. The sur- 
face of the cyst presents 
a pearly-white, glisten- 
ing appearance, the 
thinner portions of 
which are purple, green, 
or black, according to 
the color of their indi- 
vidual contents. The 
external surface ma}^ be smooth, oily, and covered with papil- 
lary growths or mucous vegetations. (Figs. 544 and 545.) 

The term proliferous is applied to those which are highly 
organized and abundantl}^ supplied with blood-vessels. The 
term proligerous is given to cysts that have the faculty of budding 




Fig. 544. — Large Ovarian Cyst, 
right. 



Patient Up- 



OVARIAN TUMORS. 



865 



or generating new cysts from or within the original growth. 
They may be spheric in shape and regular in outline, simu- 
lating a single cyst, or may be irregular from the numerous 




Fig. 545. — Ovarian Cyst. Patient Recumbent. 

nodules, indicating the presence of a multilocular tumor. These 
growths generally have a distinct pedicle. 

698. Pedicle. — The attachment of the tumor may be pedun- 
culated or sessile. The latter are frequently intraligamentary. 
The pedicle may be long or short, thin and band-like, or broad 









^5 






J&^ A 


W' 




^ 


^^^r 


^M 


^m, 


n^^ 


^ 


^ 


^i 


^W 


W^ 





Fig. 546. — Pedicle of an Ovarian Cyst. 



and thick. It is developed by the traction of the tumor and 
the resulting hyperplasia of the ovarian ligament, and by stretch- 
ing of the meso-ovarium, of the side of the broad ligament, 
and of the suspensory ligament of the ovary. The tube gener- 



866 



GYNECOLOGY. 



ally remains separated by its mesosalpinx from the tumor, 
though the ampulla is often fastened to or approaches the 
tumor, because of the strongly drawn infundibular ovarian 
ligament, and the tube is usually elongated. In ovariotomy 
the tube is generally removed with the pedicle. After the 
removal of the tumor the cut surface presents a triangular 
appearance, in which the angles are pointed or blunt, small 
or large, and formed by the stump of the ovarian ligament, 
the transverse section of the tube, and the stump of the sper- 
matic artery. The pedicle consists of smooth muscle-fibers, 
connective tissue, and hypertrophied blood-vessels. 

The pedicle varies in length from four to twenty centimeters ; 




Fig. 547.— IntraliganiLiiiar 



Cyst. 



in breadth, from two to twelve centimeters; and may be en- 
tirely absent. The difference in the development of the pedicle 
is due, in part, to the insertion of the ovary upon the posterior 
surface of the broad ligament, and partly to the origin and 
growth of the tumor. 

With the ovary originally embedded in the ligament, the 
development of the cyst in its external part will result in the 
formation of a pedicle; but the growth of the cyst toward the 
hilum may result in the spreading-out of the broad ligament 
and the formation of a subserous cyst. A cyst growing out- 
ward through the ligament may cause it to split and form two 
pedicles. As a tumor develops inward in an embedded ovary 
and spreads out the ligament, the uterus is pushed to one side, 



OVARIAN TUMORS. 



867 



and the tumor fills up the side of the pelvis, to displace the 
pelvic organs in general. Such a tumor becomes firmly fixed 
in the pelvis, pushes the peritoneum off from the uterus, in- 
vades the space between it and the bladder or rectum, and 
not infrequently partly spreads out the uterus upon its sur- 
face. Such growths are known as intraligamentary cysts. 
The cyst may be only partly subserous, having spread out 
the anterior wall of the broad ligament in advance of it, so 
that the inferior surface of the tumor is uncovered by the serous 
membrane. The separation of the posterior leaflet in such a 
growth reveals a long pedicle formed by the anterior fold. As 
an ovarian tumor develops, its increasing weight carries it 




Fig. 548. — Cyst Embedded in the Pelvis. 



backward into the retro-uterine pouch. It is very rarely found 
in front of the uterus. The subsequent development causes 
it gradually to fill the pelvis until its size no longer permits 
it to remain below the brim, when it rises into the abdom.en. 
With the change of position there is a partial rotation of the 
pedicle, which is without clinical significance unless it exceeds 
a quarter of a circle. Occasionally, the withdrawal from the 
pelvis is retarded by a marked projection of the promontory 
of the sacrum, a roomy pelvis, or extensive adhesions. Such 
a tumor as it increases in size compresses the pelvic viscera, 
forces the uterus and bladder upward, and may dissect down- 
ward until it protrudes at the vagina, as in a case under my 



868 



GYNECOLOGY. 



observation, which was covered only by the posterior vaginal 
wall. 

The nonpedunculated tumor, as it progresses, becomes 
limited by the lateral walls of the pelvis, after it has spread 
out the structure and come in contact with the parametrium. 
In its further growth it is pushed upward and to the opposite 
side, carrying the uterus. These changes frequently displace 
the sigmoid portion of the colon, placing it above and in front 
of the tumor. The intestine is frequently compressed, but not 
sufficiently to close its canal, and the large vessels are often 
obstructed. 

The presence or absence of the pedicle depends somewhat 



^;f'3l^ 




^1 ^J'^^^^-^hlp 






l^v^ 


















Fig. 549. — Adenocystoma of Ovary, Showing Papillary Formation. 
a, a. Papillary projections. 



upon the variety of the cyst. The glandular incline to a long 
pedicle, the papillary to a short or absent pedicle, and the der- 
moid to a short, strong pedicle. 

699. Structure. — The consideration of the internal struc- 
ture of the glandular cysts justifies their division into areolar, 
unilocular, and multilocular. These glandular cysts, accord- 
ing to Virchow, originate in an invagination of the proliferating 
ovarian epithelium into the stroma. Further invagination 
and proliferation of the tissue result in the formation of new 
gland tubes, from which new cysts form. (Fig. 549.) The 
continuation of these processes results in the formation of the 



OVARIAN TUMORS. 869 

many-chambered glandular or adenomatous cyst. Mary A. 
Dixon- Jones attributes ovarian growths to inflammation through 
which the tissues become embryonal and new-growths follow. 

Areolar Cyst. — A conglomeration of small cysts with a thick, 
well-developed, and vascular stroma is known as an areolar 
ovarian cyst. A number of these cysts may have ruptured 
to form a considerable sized one, or the tumor may consist of 
a very large number of small masses, none of which will exceed 
the size of a plum. (Fig. 550.) 

Unilocular cysts often attain an enormous size, but examina- 
tion discloses evidences of their previous division into numerous 
smaller cysts, so that we can safely assert that all unilocular 
cysts have originated from the multilocular. The investigation 




J'ig. 550. — Areolar Ovarian Cyst. 

of a large cyst will usually show the presence of small cysts 
in its walls, and not infrequently the remains of septa within 
its cavity. 

Multilocular cysts contain a number of cysts of varying 
size, so arranged as to present the appearance of a single tumor. 
As these individual sacs increase, their intervening walls be- 
come gradually thinned, until, one after another, they rupture 
and the sacs coalesce to form larger single chambers. Not 
infrequently the circumference of the septa remains, to be- 
come still more stretched as the tumor grows, until it forms a 
cord-like thickening upon the inner surface. Occasionally, 
the vascular structure alone remains to indicate the former 
septum. In sudden rupture the vessels of the septa are torn, 



870 



GYNECOLOGY. 



producing extensive hemorrhage into the sac, which changes 
the character of 'the cyst-contents. 

In the principal cyst we usually find a wall of three layers, 
the outside consisting of pure connective tissue, like the al- 
buginea of the ovary. The middle layer consists of loose con- 
nective tissue with numerous large vessels, while the inner 
layer is rich in cells and contains numerous small vessels. 

The external surface of the cyst is covered with columnar 
epithelium, which differs from the pavement epithelium of the 
peritoneum. The cysts are lined with a one-layered cylindric 
epithelium, which presents different forms in different tumors, 
and by its structure governs the character of the secretion in 




iM'g. 551. — Unilocular Cyst. 



the various sacs. It is only in the smaller sacs, however, that 
the true similarity of the epithelium and secretion is observed. 
In the larger cysts the epithelium undergoes degenerative 
changes; is flattened by pressure; suffers disturbances of nu- 
trition through thinning of the septal wall ; and undergoes fatty 
or albuminous changes, which cause the epithelium entirely 
to disappear from the wall of the larger cysts. Epithelial 
sprouts may remain upon the wall, forming new-growths. 

Pfannenstiel directs attention to the possibility of the forma- 
tion of papillary growths in the adenomatous cysts. This 
formation is of great variety, and is found inside as well as upon 
the surface of the tumor. Sometimes these growths are but 



OVARIAN TUMORS. 



871 



sparsely distributed upon the inner surface of a large cyst; in 
others they appear as circumscribed tufts upon one side, while 
the remaining portion is smooth; or, again, the entire cavity 
may be filled with strong, branching growths, while the quan- 
tity of fluid is very scanty. The larger the cyst, the greater 
the probability th&,t a large portion of the wall is smooth. As 
a rule, the papillae are most marked upon the side of the cyst 
toward the hilum, while the peripheral side will be scantily, 
if at all, involved. 

A great variety in the quality of these vegetations exists; 
at times only small wart -like growths, from one to two milli- 
meters high, are scattered over the surface, together giving 
a velvety or grater-like 
appearance; at others, 
branching growths of 
various sizes, up to that 
of an apple, which may 
be either broad-based or 
with a thin pedicle. All 
the changes are present 
that are found in the 
ordinary papillary cyst. 
The growths appear 
either as reddish, granu- 
lating, cauliflower - like 
projections, or as sago- 
sized masses; rarely in 
the grape-cluster form. 

Cyst - contents often 
present very great con- 
trasts in their color and 
consistency ; they may 
be found almost color- 
less, straw-colored, green, purple, or black in color; thin or thick; 
viscid or gelatinous in consistency. The contents of the various 
cysts in the same tumor will differ in color and consistency. In 
some the fluid will be thin, and in others so viscid that it will not 
flow. The fluid in the smaller cysts is more consistent, and be- 
comes thinner as the cysts increase in size, because of changes 
in the epithelium. 

The specific gravity of the fluid varies from 1002 to 1020, 
with an average of about 1012. However viscid the fluid, it is 
found absolutely structureless. Blood-corpuscles, epithelial cells, 
and crystals of cholesterin are often present. The reaction of the 
fluid is neutral or alkaline. Upon analysis various forms of 
albumin, as metalbumin, paralbumin, and albumin-peptone, are 
found. 




I- 55 



Multiloctilar Cyst. 



872 



GYNECOLOGY. 




Fig. 553. — Small Papillary Ovarian Cyst. 



700. Papillary Proliferous Cysts. — The papillary cysts show 
a marked proliferation of the connective tissue, which forms itself 
in tufts upon the inner surface of the tumor, as described in the 

complication of the 
glandular growths 
above. These 

branching projec- 
tions may distend 
the sac to bursting, 
and these tufts pro- 
ject upon the out- 
side, leading to 
rapid infection of 
the general perito- 
neum. The vegeta- 
tions spring up lux- 
uriantly over the 
surface of the ovary, 
are carried to every 
part of the perito- 
neal cavity, and not 
infrequently, by the 
action of the diaphragm, are carried to the upper surface of that 
muscle in the thorax. 

The contact of this infection with the peritoneum rapidly 
produces ascites. 
Similar vegetations 
may arise spontane- 
ously from the sur- 
face of the ovary, 
and are then know^n 
as superficial papil- 
lomata. It is prob- 
able that these are 
cases in which a 
very small cyst has 
opened and afforded 
the seed which has 
infected the exter- 
nal surface. The 
papillary tumors 
rarely attain a large 
size, and are gener- 
ally bilateral. The dendritic growths project in every direction, 
are reddish or pearly white and glistening, often three or four 
inches long, and have the appearance of stems of coral. The 




Fig. 554. — Papillar}' Tufts upon Inner Wall of Cyst. 



OVARIAN TUMORS. 8m 

masses have usually undergone a partial calcification, so that 
they break easily and without bleeding. 

701. Dermoid Cysts. — These are growths in which are found 
skin and mucous membrane, together with all the structures gen- 
erally associated with such tissues. The tissues most frequently 
found are hair, teeth, nails, and sebaceous and sweat-glands. 
Other structures, occasionally seen, are the mammas, horn, bone, 
unstriped muscle-fiber, and, rarely, tissue resembling brain. Fat 
or sebaceous material exists in the largest quantity, often at the 
temperature of the body in a liquid state. Occasionally, it is 
found in solid balls. Sutton reports finding over three hundred 
of these in one sac. Hair is frequently present in great abun- 
dance, and varies in color, length, and quantity. The hair may 
be blond, brown, or black, but bears no relation to that of the 




Fig. 555. — Surfaces of Ovaries Infected with Papillary Vegetations. 

individual. Teeth are found in about one-half the cysts; they 
may be loose, fixed, or buried in the Avail. Section through the 
tooth often reveals it situated in a bony alveolus. Beneath the 
hard crust of the tooth is found a white or reddish-yellow medul- 
lary substance. 

We may occasionally find incisors, molars, and premolars in 
the same bone. The number of teeth is often enormous. Schna- 
bel described a case which had three pieces of bone and one 
hundred teeth. Plouquet found three hundred teeth. Various 
bones have been described, as the jaw-bone, the petrous portion 
of the temporal bone, ribs, and the pelvic bones. A finger with 
articulated phalanges, nail, and nail-fold and an entire skeleton 
have been recognized. In a double dermoid removed from a girl 



8/4 GYNECOLOGY. 

of eleven years I found a well-formed half of the upper jaw, 
equipped with teeth, alveolar process, and normal mucous mem- 
brane. 

Dermoids do not always occur alone, but in conjunction with 
large glandular cysts, the dermoid forming but a small part of 
the mass. Sometimes the entire cyst will be found filled with 
sebaceous material, while careful examination, after washing, 
shows that the skin covers only a small part of the mass. 

Teratoma is a more complex form of tumor which is usually 
classed with the dermoid. It contains an even more varied 




Fig. 556. — Papillary Ovarian Cyst. 
a, a. Loculi containing papillary growths. 



structure, and resembles more the solid growths than the cystic. 
It often attains an enormous size, and contains the various 
structures of the dermoid and cartilage and a large amount of 
connective tissue. Dermoid growths may appear at any age. 
They have been found in children at birth and in women of 
ninety years. 

The contents of a dermoid are exceedingly irritating, and 
every precaution should be practised to prevent the peritoneal 
cavity from being soiled. I saw a patient in whom an attempted 
aspiration resulted in drawing out a wisp of hair ; the patient at 



OVARIAN TUMORS. 875 

once developed peritonitis, which an eariy operation failed to 
prevent becoming fatal. 

702. Parovarian Cysts. — The parovarium is situated in the 
lateral part of the mesosalpinx, and is the remains of the sexual 
part of the Wolffian body. It resembles in its arrangement a 
comb, the back of which is directed toward the tube, while the 
teeth, some twelve to fifteen in number, converge toward the 
ovary. They are lined with large cylindric epithelium and ter- 
minate in blind extremities. The tumors which originate from 
this structure are almost always cystic and subserous, and con- 
sequently have a double wall. The external peritoneal one is 
easily separable. The pedicle consists of the tube and of the 




Fig- 557- — Dermoid Ovarian Cyst. 

median ovarian and the suspensory ligaments. Torsion of the 
pedicle, when long, can easily occur. There are two kinds of 
cysts which arise from the parovarium, of which the most fre- 
quent are the small pedunculated, connected with Kobelt's 
tubules, which rarely become larger than a pea and are of no 
clinical significance. The more important are the -sessile, which 
remain between the folds of the broad ligament and burrow into 
it as they enlarge. These cysts are usually small, though Kum- 
mel describes one that weighed forty-two pounds. In the large 
cysts the tube becomes elongated. The contents of the cyst are 
clear and limpid, with a specific gravity of loio and an alkaline 
reaction. 

The parovarian and broad ligament cysts form about eleven 



876 



GYNECOLOGY. 



per cent, of the abdominal tumors of pelvic origin, and both 
proliferating and dermoid growths have been found in this 
situation. 

These cysts are distinguished from the ovarian, first, by the 
ease with which the peritoneum can be stripped off; second, by 
the ovary being generally found attached to the side of the cyst ; 
third, by the cyst being unilocular ; fourth, by the Fallopian tube 




Fig. 558. — Fibromyoma of Ovary 



Fig. 559. — Sarcoma of the 
Ovary. 



stretched over the cyst and never communicating with it; and, 
lastly, by the gradual thickening of the mesosalpinx. 

703. Solid Ovarian Tumors. — The solid growths of the ovary 
comprise five per cent, of the cases that present themselves for 
operation. These tumors are innocent and malignant, and may 
become cystic. 

704. Fibromyoma, the benign form, is a rare tumor, but is 
the most common species of solid ovarian tumor. It closely 



OVARIAN TUMORS. 877 

resembles the uterine fibroma, and is frequently accompanied by 
ascites. Its growth is slow, and the mass retains the normal 
shape of the ovary. Adhesions are rare; indeed, owing to the 
peritoneal fluid, the mobility is increased. Occasionally, we have 
a growth — the fibroma — in which the minute structure consists 
of wavy bundles of closely packed fibrous tissue intermixed with 
small round cells. Williams describes one of these that weighed 
seven pounds seven ounces; Doran, one of seventeen pounds. 
The myomatous variety is more frequent, and occasionally under- 
goes calcareous degeneration, when it may be mistaken for an 
osseous tumor. 

An apparent hypertrophy, instead of atrophy, of the corpus 
luteum results in the formation of a growth, occasionally reaching 
the size of a walnut, which Dr. Mary D. Jones pronounces a 
gyroma, and believes to be closely connected with the endothe- 
lium. It probably develops from the corpus luteum when in the 
cortex, and from the endothelium in the medulla. Leopold de- 
scribes a peculiar form of ovarian fibroma containing alveolar 
spaces packed with epithelioid cells. They are produced by 
dilatation of the lymphatic and capillary channels and the pro- 
liferation of their endothelium. 

705. Sarcoma of the Ovary. — Sarcoma resembles in form, size, 
and color the fibroid, excepting that its surface is smoother. Its 
consistence is softer than the fibroid, though it contains much 
fibrous tissue, which renders the diagnosis at times difficult to de- 
termine. Sarcomata occur as round-cell and spindle-cell growths ; 
when the latter predominate, the tumor is more solid and more 
strongly resembles the fibroma. The muscle -fibers are longer 
and the nuclei are more slender and rod-like. The round-cell 
structure is softer, often presenting macroscopically medullary 
properties similar to those of medullary cancer, and under the 
microscope are found large layers and nests of round cells, united 
with irritation cells, and penetrated by numerous blood-vessels of 
every caliber. 

Spindle and round cells are frequently combined, while myx- 
omatous transformation exists in both kinds, but cartilage and 
bone formation rarely occurs. 

Combinations of sarcoma with adenoma are observed in the 
walls of the larger cysts, sometimes with sarcomatous degenera- 
tion of the stroma. In places, large alveoli are separated by 
vascular connective tissue, which contains large cells undergoing 
fatty degeneration and resembling carcinoma. This condition 
Spiegelberg has called sarcoma carcinomatosum. 

706. Carcinoma of the ovary is a much more frequent condi- 
tion than sarcoma. The medullary variety is the most common, 
and may form a tumor as large as a man's head. The disease 



878 GYNECOLOGY. 

occurs primarily, but much more frequently as a secondary 
manifestation. 

707. Endothelioma of the Ovary. — A growth is occasionally 
found in the ovary which originates from the endothelium of the 
lymph-spaces or blood-vessels of the organ. It has been pre- 
viously classed by pathologists with both sarcoma and carcinoma, 
resembling the sarcoma from its frequent metastasis through 
the blood-vessels, a carcinoma in consisting of nests of cells with 
a fine stroma. The growth rarely attains a great size, — not larger 
than an orange or fist, — forms a solid tumor, and is a rather firm 
whitish growth. This same structure not infrequently is found 
complicating the glandular proliferating cysts, and gives evidence 
that many of these tumors, if carefully investigated, would show 
the presence of malignant conditions. 

708. Etiology. — Very little is yet known as to the general 
cause of ovarian tumors. Three theories for their origin have 
been presented: (i) The Cohnheim theory, which attributed 
their growth to the retention of embryonic products; (2) the 
theory advanced by Mary A. Dixon- Jones, that they were always 
the result of previous attacks of inflammation, and that the in- 
flammatory condition of the ovaries gave rise to embryonal 
tissue from which the growth subsequently developed; and (3) 
the theory of parthenogenesis, or the development of the non- 
fecundated ovum as the result of some irritation. The first and 
second theories are those which have the greatest number of 
advocates at the present day. According to the first, der- 
moids are derived from the infolding of the ectoderm in embryonic 
life, and these cells during subsequent irritation take on active 
growth and result in the formation of the various tissues found 
in a dermoid growth. It is claimed by the advocates of the 
theory of parthenogenesis that there are some structures found 
in the dermoid ovary which would require the infolding of all 
of the layers of the blastoderm in order to complete their develop- 
ment. The advocates of the first theory, however, direct at- 
tention to the fact that striated muscle is never found in the 
dermoid cysts. The character of irritation which sets in motion 
the development of these growths, whether mechanical'or chemic, 
animate or inanimate, or whether it differs in the various kinds of 
tumors, is as yet unknown. The frequent occurrence in a 
cystadenoma of double-sided growth from the covering epithe- 
lium favors the belief in a chemic irritation which has proceeded 
by way of the uterus and tubes. The theory of the parasitic 
origin of tumors is as yet unproved, though the analogous 
course of tumor disease with infection has demonstrated that the 
development of various kinds of tumors in the different tissues 
of the body from metastatic deposits is of great interest. 



OVARIAN TUMORS. 879 

The susceptibility to the influence of tumor exciters greatly 
varies in different individuals ; heredity, acquired disposition, age, 
trauma, scar formation, and inflammation are important factors. 
Of the influence of heredity little is known, though the occurrence 
of ovarian cysts in several women of one family is quite frequent. 
The age has no especial significance, as they occur in every 
period of life. The glandular cysts are more frequent between 
the thirtieth and fiftieth years. All varieties are less frequent in 
childhood and old age. Fetal tumors are rare, and generally 
consist of simple follicular cysts. These cysts increase in fre- 
quency as the child approaches puberty, probably then induced 
by the congestive hyperemia. 

Ovarian growths are more frequent in the single than in the 
married. Scanzoni indicates chlorosis as a predisposing factor, 
and Fenwick, tuberculosis ; but these are difficult to demonstrate. 

709. Natural Progress. — Proliferating cysts in the advanced 
stages grow more rapidly than either the dermoid or solid tumors, 
unless the latter are malignant. About the early stage of ovarian 
tumors but little is known, as they are usually well advanced 
before they come under the observation of the physician. The 
growth is probably slow. In dermoids and in benign solid tumors 
the growth throughout is slow. A rapid increase in the size of a 
growth, noticeable from day to day, is a symptom due to hemor- 
rhage. With the pelvic structures in a normal condition, the 
cystic ovary drops by its weight into Douglas' pouch, a little to 
one side of the median line. As it increases it advances in the 
direction of least resistance, which is upward, and pushes the in- 
testines before it, until it rises out of the pelvis and impinges 
against the abdominal wall, when it assumes a central position. 
The pedicle, at first anterior and inferior, is now directly beneath, 
and often becomes posterior. The tumor lies directly above the 
uterus, and, resting upon the brim of the pelvis, causes but little 
inconvenience. Occasionally, the tumor becomes impacted in 
the pelvis through irregularities in its growth or the formation 
of extensive adhesions. Sometimes the tumor pushes the broad 
ligament before it, or, when it develops in the hilum, it will 
spread out the ligament and become an intraligamentary growth. 
Once the growth rests upon the pelvis, in its further advance it 
pushes the intestines upward and laterally. If undisturbed, the 
enlargement becomes very great, the diaphragm is pushed up- 
ward, severe pressure symptoms follow, and the action of the 
heart and lungs is obstructed. The limbs appear as mere appen- 
dages to the enormous abdomen. The pressure affects the circu- 
lation, respiration, digestion, and the renal secretion. There are 
marked suffering, emaciation, and the characteristic facial ex- 
pression known as facies ovariana. The presence of ovarian 



880 GYNECOLOGY. 

tumors does not interfere with ovulation and menstruation, even 
though both ovaries are involved, so long as any portion of the 
ovarian stroma remains undestroyed. Thornton reports a case of 
pregnancy with bilateral dermoid disease. In solid tumors amen- 
orrhea is due to the total destruction of the Graafian follicles. 

710. Symptoms. — In their early stages ovarian tumors rarely 
produce any symptoms. Movable tumors generally come first to 
observation when they rise out of the pelvis. An apple-sized 
tumor will occasionally, though movable, cause unpleasant symp- 
toms, such as pain in the sacrum, which extends down the leg. 

Intraligamentary tumors or those prevented by adhesions 
from rising produce symptoms as soon as they fill the pelvis, 
especially by obstruction to defecation and micturition. As 
the tumor increases, the sensations of pressure and unpleasant- 
ness are aggravated. Besides the eft'ects given in the description 
of the progress, the skin becomes stretched, forms strise, and 
swelling of the navel and hernia occur. More rarely, from the 
pressure upon the great vessels, there are edema and varicosities 
in the legs, sexual apparatus, and skin of the abdomen. 

Albuminuria is present, and diminution of the urine from 
compression of the renal veins is observed, which disappears 
with the removal of the pressure. Severe compression symptoms 
from the presence of very large tumors are now rarely seen. 

Uterine or vaginal prolapse sometimes complicates the condi- 
tion, but more frequently ascites and fluid collections follow the 
rupture of a cyst. 

Menstruation is usually unaffected, and sometimes continues 
regular when subsequent microscopic investigation has failed to 
show any functionally capable structure. Menstruation disap- 
pears comparatively early in those cases in which the follicles 
perish from the development of sarcoma or carcinoma, and in the 
papillary cystadenoma, when bilateral. In contrast to fibroid 
tumor, the menstruation decreases, and a disposition to the 
menopause is betrayed, not from absent ovulation, but as the 
result of constitutional conditions. Amenorrhea may exist for 
several years and menstruation may return after the removal of 
an ovarian cyst. In intraligamentary growths, especially the 
papillary cystadenoma, severe menorrhagia occurs from pressure 
upon the uterine veins. 

711. Complications. — Ascites occurs infrequently with cystic 
growths, unless from rupture, but is very frequent in the solid 
tumors. The cause is unknown. It can arise from pressure 
upon the vense cavae and large abdominal veins. Edema may 
involve one or both legs. Distention occurs in the pelvis of the 
kidney and in the ureter from pressure along the course of the 
latter. The most frequent complication is the formation of 



OVARIAN TUMORS. 881 

adhesions between the surface of the tumor and the omentum, 
the intestines, the uterus, the bladder, and the abdom- 
inal wall. These adhesions arise from inflammation, peritonitis, 
and sometimes painlessly. They possibly arise from the loss of 
surface epithelium of the cyst, through friction; fibrinous exuda- 
tion results, and the formation of adhesions between adjacent 
surfaces. The adhesions become firm, dense, often thread-like, 
and between the omentum and the growth may convey vessels 
of sufficient size to be an important factor in the blood-supply. 
Dermoids are frequently complicated by adhesions. When 
adhesions occur between the tumor and the bladder or the in- 
testine, the cyst may open into either, and thus discharge its 
contents. A tuft of hair may project from a dermoid into the 
rectum or the bladder. Adhesions are of importance from the 
increased difficulty in the removal of the growth. It is fre- 
quently exceedingly difficult to distinguish the cyst -wall from the 
parietal peritoneum. 

Torsion of the Pedicle. — A moderate twisting of the pedicle to 
90 degrees produces no symptoms ; it is only when the torsion is 
sufficient to influence the circulation, or above i8o degrees, that 
disturbance is occasioned. A slight twisting always occurs with 
the elevation of the cyst from the pelvis. The right -sided tumor 
turns to the left, and the left-sided to the right. The cause of the 
torsion is unknown. Kiistner ascribed it to peristalsis and the 
changes from the distention of the rectum ; Carlo, to sudden belly 
pressure; Mickwitz, to contraction of the trans versalis muscle. 
The influence of pregnancy and changes of position in a relaxed 
abdomen which contains a tumor with a long pedicle are factors. 
This torsion may readily arise from manipulation to determine 
the diagnosis. I saw it occur in a young girl who had been 
thrown upon the floor by her companion, who sat upon her abdo- 
men. The torsion can occur with very small tumors which are 
still within the pelvis, in which it most probably arises from the 
varying distention of the bladder and rectum. The twist may 
involve but one or two turns of the pedicle, though as many as 
six twists have been observed. The tube usually shares in the 
twisting, and torsion of the uterus has infrequently occurred. 
Torsion of the pedicle can take place in any variety of tumor, 
though from its greater frequency it is found most often in the 
cystadenoma. Dermoids and parovarian growths also show a 
marked tendency to undergo pedicle -torsion. The tendency to 
torsion of the pedicle is favored by the existence of a long, mem- 
branous pedicle, a spheric form of the tumor, and a smooth siir- 
face. The twisting is still further favored by pregnancy, labor, 
and child-bed, through the changing relations of the organs in 
the abdominal cavity. 

56 



882 



GYNECOLOGY, 



The results of the torsion are dependent upon the rapidity 
with which it has occurred. The torsion causes obstruction of 
the vessels, in which the thin-walled veins suffer before the more 
resistant arteries. There necessarily results an increased engorge- 
ment of the blood in the tumor. Solid tumors are completely 
penetrated by blood, and cystic gro^^i:hs undergo hemorrhagic 




Fig. 560. — -Torsion of the Pedicle. 



infiltration of the walls as well as of the contents. The surface 
presents a black, blue, or dirty brown color, the cyst rapidly 
increases in volume, and, as a result, easily breaks down. A fatal 
result can occur from hemorrhage into the abdominal cavity. 
More frequently hemorrhage is arrested, but the nutrition of the 
tumor suffers. The covering epithelium is lost, and extensive 



OVARIAN TUMORS. 883 

adhesions occur between the surface of the tumor and the sur- 
rounding structures, as the omentum, intestines, and parietal 
peritoneum. 

These adhesions are, at first, very loose, then become organ- 
ized, and the growth thereby obtains a new source of nutrition, 
by which it maintains its size or proceeds to new growth. Further 
twisting leads to obstruction of the arteries, which is followed by 
necrosis of the growth. Necrosis is followed by shrinking of the 
tumor from the absorption of its fatty constituents, though it 
rarely disappears. It can become calcified. Peritonitis, with the 
formation of extensive ascites, almost always results. The peri- 
tonitis arises independent of micro-organisms, and is due to the 
irritation from the presence of a foreign body or to the chemic 
products of the tumor. An infection can occur through the tube 
or from kinking of the intestine. Sometimes suppuration of the 
tumor and pyemia ensue. A slight torsion can bring about 
edema instead of hemorrhage, and ascites instead of peritonitis. 
The pedicle may be found attenuated, or its thickness may be 
doubled. The dermoid growths are sometimes found free in the 
abdominal cavity or in pedicle-like adhesion with other structures. 
A dermoid under my observation was held in front of the uterus 
by adhesions above to the omentum, and below to the perito- 
neum ; the tube and upper part of the broad ligament upon the 
left side had entirely disappeared. The separation was evidently 
old, for the wall of the growth had undergone calcareous degen- 
eration. Ileus has resulted from the adhesion of a loop of intes- 
tine to the tumor or to its pedicle. 

Symptoms. — Not infrequently there are no symptoms of tor- 
sion. Such cases- are usually recent or the torsion has been 
slight. It may be suspected when the patient is taken with 
severe pain in the belly, associated with meteorism, and sensi- 
bility to pressure, acceleration of the pulse, sometimes also sin- 
gultus, vomiting, and fever. In torsion of high degree indications 
of intra-abdominal bleeding appear, Avith not infrequently marked 
collapse. In the chronic condition the pain and unfavorable 
symptoms are more gradual, though many patients are bedridden 
and show a distinct loss of strength, occasioned by the absorption 
of the altered constituents of the tumors producing a condition 
resembling cachexia. 

Inflammation and Suppuration of the Cyst. — Cysts can undergo 
inflammatory and suppurative changes, though much less fre- 
quently than formerly, as puncture of the cyst is not so often 
practised. In some tumors the contents of which resemble pus, 
the microscope demonstrates that the material consists of epithe- 
lium and cell detritus, but not of leukocytes. The inflammation 
is mostly communicated by the tube and intestine; the latter 



884 



GYNECOLOGY. 



especially when adhesions have taken place between the intes- 
tine and the sac. The opportunities for infection are increased 
by parturition and the puerperium, as a result of the possible 
trauma occasioned during the labor. Dermoid tumors are in- 
clined to suppuration, formerly supposed to be due to the peculiar 
pus-exciting character of their contents, but much more probably 
the result of injury which the tumor has undergone during its 
long retention within the body. We have already seen that the 
dermoid was prone to torsion of its pedicle, and its contents are 
an excellent culture- medium for the propagation of bacteria. 
Symptoms. — The occurrence of inflammation and suppuration 

is characterized by 
fever and typhoid 
phenomena, which 
vary in intensity ac- 
cording to the nature 
of the infection. The 
patient does not ex- 
perience much pain 
unless peritonitis is 
associated. The 
pulse becomes very 
rapid and emacia- 
tion is progressive. 
Adhesions to the 
suppurating tumor 
occur, and the pus 
makes its exit, as in 
ovarian abscess, into 
the bladder, the rec- 
tum, or the vagina. 
It is but rarely 
that the pus is com- 
pletely evacuated 
and that spontaneous recovery results. Death usually follows 
from pyemia. A rupture into the peritoneal cavity is quickly 
followed by fatal peritonitis. The evacuation of such a tumor 
through the bladder produces the greatest distress, as hair, teeth, 
and pieces of bone are discharged, sloughs become impacted in 
the urethra and induce cystitis, and there are retention of urine 
and marked vesical tenesmus. Fragments which remain in the 
bladder are coated over with urine salts, and become the nuclei 
of calculi. 

Rupture of Cystic Tumors. — Rupture of a cyst may occur sud- 
denly, the result of a fall or blow, or can gradually result from 
changes in the cyst-wall. It occasionally follows from internal 




Fig. 561. — Dermoid Which Had Lost Its Original 
Relations and Was Nourished by Adhesions 
from the Omentum. . 



OVARIAN TUMORS. 885 

pressure caused by the growth of the tumor. The latter accident 
produces no symptoms, and it is only exceptionally that hemor- 
rhage complicates spontaneous rupture. In papillary growths 
the pressure of the vegetations causes thinning of the cyst wall, 
and, finally, rupture ; or the growths project through the wall of 
the cyst, to extend over its external surface. Rupture of a cyst 
can occur into the surrounding viscera, but more frequently takes 
place into the peritoneal cavity. In very thin-walled cysts this 
rupture occurs easily. Manipulation to determine the diagnosis, 
changing the position in bed, the act of coition, vomiting, may 
produce it, and frequently it occurs without assignable cause. 
The influence of the accident will naturally depend upon the 
character of the cyst-contents. Often, in the unilocular cysts, 
rupture into the peritoneal cavity is attended with no un- 
toward symptoms, beyond an excessive flow of pale urine. The 
patient will often pass several gallons of urine in twenty-four 
hours, and the abdomen, which was large, will become flattened, 
flabby, and readily permit the residual sac to be recognized by 
palpation. In single and parovarian cysts recovery can occa- 
sionally follow the rupture. Generally, the opening is closed 
by adhesions, and the fluid reaccumulates. In some cases the 
accident is followed by high temperature, rapid pulse, vomit- 
ing, pressure at stool, and diarrhea, which indicate the 
absorption of the contents and the development of a form 
of auto-intoxication. In multilocular and dermoid growths the 
rupture into the peritoneal cavity is ordinarily followed by in- 
fection, a rapidly developing peritonitis, and, finally, death. Such 
a termination is probable not only in dermoid, but also in those 
cysts containing colloid material and pus. In the papillary cysts 
rupture results in the infection of the peritoneum, the formation 
of ascites, and the development of vegetations over the entire 
cavity. Sometimes an artery is torn in the rupture, and m^arked 
hemorrhage, with profound anemia, follows. Profound collapse 
has been noted. 

The occurrence of rupture is recognized by the disappearance 
of, or diminution in the size of, the tumor, the recognition of free 
fluid in the peritoneal cavity, peritonitis, collapse, diarrhea, and 
diuresis. The accident can be mistaken for torsion. Rupture 
into the intestine is evident from the character of the discharges 
and should be suspected when a profuse watery discharge escapes 
from the bowel. External rupture is usually easily recognized. 
When the discharge is pus or ichorous material alone, it is often 
difficult to determine whether it is from a cyst or an abscess 
in the walls. 

Complication of Ovarian Tumor with Pregnancy. — The exis- 
tence of ovarian growths does not preclude the occurrence of 



886 GYNECOLOGY. 

pregnancy, though their coexistence is comparatively rare. It is 
more frequent in the one-sided, though it occurs sufhciently often 
in double-sided, disease to demonstrate its possibility as long 
as any functionating portion of ovary remains. The compHca- 
tion can occur with any variety of ovarian tumor, though it 
is more likely to complicate the slow-growing forms — the dermoid 
and the pseudomucin — than the others. Numerous cases are 

recorded in which the 
patient carrying an 
- ovarian tumor has suc- 

cessfully run the gaunt- 
let of several pregnan- 
cies. The existence of 
.1 such a tumor, however, 

f does increase the dis- 

tressing symptoms and 
the danger of preg- 
nancy. There is not 
the same tendency to 
^ * rapid growth of the 

, / \^^ cyst during pregnancy 

as exists when a fibroid 

I growth is complicated 

I I i \ ^ ^ by the same condition. 

:, ^, , The assertion that the 

/ x^''"' occurrence of preg- 

> . nancy favors malig- 

'\ V .. .^ nant degeneration in 

f "■ s^-^ ^-^., .^^ the cyst is unproved. 

The occurrence of car- 
cinoma in a cyst dur- 
ing pregnancy is no 
proof that it was not 
7 previously there, or 
that it would not have 

Fig. 562.— An Ovarian Cyst beneath a Pregnant Occurred had preg- 

Uterus. nancy never existed. 

The changing relations 
of pregnancy, labor, and the puerperium undoubtedly do favor the 
occurrence of torsion of the pedicle, and the delivery of the fetus, 
whether naturally or by the use of instruments, not infrequently 
crushes or bruises the cyst so that it ruptures or undergoes inflam- 
mation and suppuration. While the varying relations of preg- 
nancy, labor, and the puerperium exert an injurious influence upon 
the progress of the tumor, it can, on the contrary, greatly disturb 
these processes. The diminished space in the abdomen affords less 



r\ 



r 



OVARIAN TUMORS. .887 

room for the normal development and increases the danger of 
abortion and premature delivery. Abortion has been frequently 
reported as a result of the retroflexion of the uterus produced by 
the tumor. In labor a large tumor can materially interfere with 
the normal forces of delivery by decreasing the activity of the 
contractions and by altering the situation of the uterus. Much 
more worthy of consideration is the situation of a tumor of small 
size in the pelvis, below the uterus, where it acts as an obstruc- 
tion to the progress of the child's head. If these are not flattened 
or pulled out of the pelvis, the head of the child can not enter, 
and, unless otherwise alleviated, labor may terminate in rupture 
of the uterus, tearing of the vagina, or bursting of the cyst. 
Such complications are necessarily attended with danger. The 
puerperium can be complicated by gangrenous processes in the 
tumor and its pedicle, following the injury of laor. 

The coexistence of the ovarian tumor with pregnancy, when 
large, causes increased difficulty in respiration, through pressure 
upon the diaphragm, and can cause danger to life by the pressure 
and the tendency to albuminuria and edema. The tendency to 
torsion of the pedicle, to rupture of the sac, and to subsequent 
inflammation naturally clouds the prognosis. 

When the cyst is situated in advance of the uterus, an effort 
should be made to push it up, and, upon failure, we may be left 
to the choice between delivery of the growth through a vaginal 
incision or its puncture through that canal and its removal after 
delivery. In the early months of the pregnancy operative inter- 
ference for the removal of the tumor has but little influence upon 
the progress of the pregnancy, and should be considered when- 
ever the size and situation of the growth threaten the successful 
termination of the pregnancy. 

712. Degenerative Changes in the Cyst- walls. — The cyst-walls 
can undergo the following degenerative processes : 

First, calcification, which most frequently occurs in the inner 
layer of the main cyst-wall in the form of small granules or 
plates of lime, or the formation of psammous bodies similar to 
those seen in the papillary cysts. The calcification is increased 
with the impairment of nutrition following gradual torsion. In 
a case of dermoid which came under my observation the deposit 
was so extensive that the tumor resembled a calcareous fibroid. 

Second, fatty degeneration occurs in the papillary cells and in 
the connective tissue of walls of the cyst. This process is en- 
hanced by impairment of nutrition. The change in the septa of 
cysts occurs from the pressure of their contents, and ends in their 
partial or complete destruction. The presence of a large amount 
of fat in the walls is an evidence of slow growth. 



GYNECOLOGY. 

Third, atheromatous changes, which generally occur in the 
inner layer of the wall. 

Fourth, changes due to infarctions, which are indicated by 
whitish, opaque bodies found in the septa and surrounded by a 
red zone. 

713. Diagnosis. — In the diagnosis of ovarian tumors the 
physical signs are ascertained by the employment of inspection, 
palpation, percussion, and auscultation. The information de- 
rived by these procedures has been given. (Sections 160 to 164.) 
The difficulty in the diagnosis will depend upon the size, situ- 
ation, relation, and complications of the tumor. 

The questions to be considered are: (i) Is the abdominal 
enlargement under observation a tumor ? (2) The existence of a 
tumor recognized, is it an ovarian growth? (3) An ovarian 
tumor admitted, its relations to the surrounding parts and the 
existence or absence of a pedicle or of adhesions remain to be 
determined. (4) The variety of the ovarian tumor. 

First, Is the distention of the abdomen an intra-abdominal tumor f 
This, at first thought, may seem an unnecessary question, but the 
frequency with which various enlargements of the abdomen are 
mistaken for such growths, and the occasional difficulty in 
arriving at a certain determination, fully justify the careful con- 
sideration of the subject. For convenience of study we divide the 
ovarian growths into small, or those situated within the pelvis, 
and large, when they are resting upon the pelvic brim. 

The abdominal enlargements, other than tumors, with which 
an ovarian tumor can be confused are obesity, desmoid tumor of 
the abdominal walls, ventral hernia, tympanites, fecal accumula- 
tion, distended bladder, ascites, and localized peritoneal effusion. 

Obesity. — A large, pendulous abdomen, from the accumulation 
of fat within its walls or in the omentum, is sometimes mistaken 
for an ovarian tumor. The history of its development and the 
distribution of adipose tissue to other parts of the body, con- 
trasted with the general emaciation of an ovarian cyst, should 
assist in determining the diagnosis. The thickness of the fat 
accumulation can be pretty accurately estimated by grasping a 
fold of the skin and subcutaneous tissue between the thumb and 
fingers. 

Desmoid Tumor of the Abdominal Walls. — This growth, which 
is infrequent, develops in the muscle- wall, and partakes of the 
nature of a fibroid. Generally, from its weight, it forms a depend- 
ent tumor, which sometimes extends to the knees. In rare 
instances it grows in, pushing the peritoneum forward as a part 
of its covering and may fill up the abdominal cavity. It is quite 
movable with the abdominal wall, and is superficial and very 
hard. Its situation in the wall, covered by the skin and super- 



OVARIAN TUMORS, 



889 



ficial fascia, and the determination by vaginal or rectal examina- 
tion of the absence of any connection with the pelvic viscera, 
determine its character. 

Ventral Hernia. — Twice in diastasis of the recti muscles with a 
large protrusion of the viscera have I been called a long distance 
to operate for supposed ovarian cyst. Palpation of the intestinal 
coils, the resonance upon percussion, and the observation of the 




Fig. 563. — Desmoid Tumor of Abdominal Wall. 



peristalsis, readily seen through the thin covering, of skin and 
peritoneum, should have excluded the diagnosis of a cyst. 

Tympanites. — A localized tympanites or phantom tumor, a 
condition similar to pseudocyesis, is sometimes mistaken for an 
ovarian cyst. The loud volume of resonance obtained by per- 
cussion should be considered as contraindicating the probability 
of the existence of a cyst. It is true that in rare instances a 
communication of a cyst with the bowel will permit it to become 



890 GYNECOLOGY. 

resonant. A similar condition will arise from decomposition of 
cyst-contents, by which gas forms in the cavity. Even in these 
cases a sense of fluctuation can be secured, which is absent in 
the phantom tumor. The latter tumor will entirely disappear 
while the patient is under an anesthetic, to return as soon as the 
patient recovers. 

Fecal Accumulation. — An accumulation of feces is sometimes 
called a fecal ttimor. It forms in the colon, and when in the 
transverse portion of the gut, may descend and lie directly over 
the pelvis. These accumulations are occasionally quite exten- 
sive, but are recognizable by their length, by the peculiar sensa- 
tion under palpation, and by the possibility of leaving an imprint 
upon pressure, but most of all by the fact that they disappear 
under the administration of purgatives and enem.as. 

Distended Bladder. — A distended bladder forms a tumor in 
the lower part of the abdomen which fluctuates and may very 
readily be mistaken for an ovarian cyst. This suspicion is 
apparently confirmed by the information that the patient is con- 
stantly passing urine. The fixed position, and the bulging of 
the anterior wall of the vagina, should be sufficient to indicate 
the use of a catheter, when the tumor will disappear. It should 
be the invariable rule to empty the bowel and bladder preliminary 
to the examination of an abdominal tumor. 

In pregnancy, fibroid tumor, or even a simple ovarian tumor 
impacted in the pelvis the urethra may be so distorted and 
compressed as to render necessary the use of a soft male catheter. 

Ascites. — In uncomplicated ovarian cysts the differential diag- 
nosis from ascites is not difficult to make. The cysts have, in 
common with ascites, enlargement of the abdomen, fluctuation, 
and the symptoms arising from pressure against the diaphragm. 
Not infrequently both conditions will be characterized by pro- 
gressive loss of strength and flesh and by more or less edema of 
other parts of the body, but there is a marked difference in the 
manifestation of these symptoms when we come to analyze them. 
The enlarged abdomen in ascites is more or less flattened and its 
widest diameter is transverse, while the ovarian cyst is most 
prominent in the vertical diameter and is narrow from side to 
side. Fluctuation is very distinct over the abdomen in ascites 
and in unilocular cysts, but the wave of fluctuation will be found 
to extend nearer to the vertebrae in the former. In the well-filled 
cyst the projection of the vertebrae prevents the approach of the 
fluid to the lumbar regions. In multilocular cysts the wave of 
fluctuation is more broken, and frequently is only recognized as 
a sensation of elasticity. The loss of strength is often more 
marked in ascites, while the appearance of emaciation is greater 
in the cyst. In renal and cardiac dropsy there is much greater 



OVARIAN TUMORS. 



891 



disposition to anasarca. In a very advanced and large ovarian 
tumor the pressure may induce considerable dropsy of the 
extremities, but the abdominal distention is in much greater 
proportion. 

On palpation the ovarian tumor presents greater resistance 





l^^m^ INTESTINAL .,^>^) 
jZio/^'L±_ RESONANCE-^ 




Fig. 564. — Relative Zones of Dullness and Resonance in Ascites. 



and can frequently be outlined and its surfaces distinctly deter- 
mined. The abdominal surface can be moved over the tumor 
and the upper margin is easily recognized. The existence of 
adhesions or the presence of a large quantity of fluid may obscure 



892 



GYNECOLOGY. 



the conditions. Percussion affords the most valuable informa- 
tion. In ascites there is a distinct zone of resonance over the 
center of the abdomen, or the point of greatest prominence, while 
the more dependent portions are dull. The zone of resonance 



b 




DULNCS^ OVER QJST 



r?^ 



~tW 



pig_ ^52. — Relative Zones of Dullness and Resonance in Ovarian Cyst. 

changes with the position of the patient. In ovarian cyst, on 
the contrary, there is dullness upon percussion over the whole 
surface of the tumor, and resonance only after we have passed 
beyond its limits, which is unchanged by position. As the tumor, 
in its growth, presses the intestines upward and to the opposite 



OVARIAN TUMORS. 893 

side before it, the resonance will generally be discovered above, 
and on the side opposite to that upon which the tumor has 
originated. Occasionally, in a distended colon, resonance may be 
secured over it in ascites. When the abdomen is very greatly 
distended, or when inflammatory conditions bind down the in- 
testines, resonance will be absent upon superficial percussion, but 
may be easily determined when more pressure is used. The pres- 
sure displaces the intervening layer of fluid and permits resonance 
to be obtained. In tubercular peritonitis and in hepatic dropsy, 
when the mesentery has undergone contraction and the peri- 
toneum is very much thickened, the diagnosis can be so obscure 
as to require an abdominal incision to determine it. 

Ascites may complicate an ovarian cyst, when, by displace- 
ment of a layer of fluid, the hand will come in contact with the 
cyst. The amount of resistance will afford information as to 
whether the tumor is solid or cystic. The complication of ascites 
can be regarded as an evidence of malignancy or of some degen- 
erative process. The greater the amount of ascites, the more 
probable the malignancy. I have, however, seen very large 
ascitic accumulations from necrosis of a cyst after torsion of its 
pedicle. The uterus is freely movable in ascites, while in ovarian 
cyst it is but slightly movable, and displaced either downward 
and backward or upward and forward. In ascites arising from 
ruptured papillary cysts a dense, thickened mass is recognized 
upon each side of the uterus, which should cause a suspicion as 
to the character and origin of the disorder. 

Localized Peritoneal Effusion. — Localized collections within 
the abdominal cavity offer great difficulties in determining the 
diagnosis. Such accumulations are generally the result of tuber- 
cular disease, and the history of the development of the disorder, 
the general condition of the patient, and careful investigation of 
the abdomen will afford an intimation as to its character. It 
was my misfortune recently to mistake a collection within the 
lesser peritoneal cavity for an ovarian cyst. The abdomen pre- 
sented the characteristic appearance of a large ovarian cyst. A 
vaginal examination would have revealed the uterus and ovaries 
below a collection which did not dip into the pelvis, but, unfor- 
tunately, no such investigation was made. The diagnosis of 
ovarian growth was accepted upon the external ■ appearance. 
Upon abdominal incision the general peritoneal cavity was free 
from fluid. An apparent cyst upon which the intestines were 
spread projected into the incision, from which over three gallons 
of straw-colored fluid were withdrawn, and investigation demon- 
strated the character of the cavity. 

Second, Is the tumor under observation an ovarian tumorf The 
physical signs vary with the size and situation of the tumor. In 



894 



GYNECOLOGY. 



the early stage the tumor is entirely within the pelvis, and its 
position varies. When it reaches the size of a hen's egg, the 
tumor falls into the pelvis, where it remains until it becomes 
too large to be longer accommodated in that situation. Its 
relation to the corresponding side of the uterus permits its 
character to be determined by conjoined manipulation. When 
the growth has been complicated by peritonitis, the diagnosis may 
be difficult. Small tumors usually feel firm because they are not 
sufficiently large to afford fluctuation, or even elasticity. The 
latter is of importance, and is generally absent in proliferating 
cystomata, in dermoids, and even in small single cysts. When 




Fig, 566. — Hegar's Method of Determining Relation of Tumor to the Uterus. 



we are unable to separate the tumor from the uterus, and conse- 
quently to determine the existence of a pedicle, the latter can be 
ascertained by Hegar's method. This, while the patient lies upon 
her back, consists in seizing the uterus with a vulsellum and 
dragging it well down, while two fingers in the rectum follow its 
borders to determine its relation to the growth, or the hand over 
the abdomen can depress the fundus and thus recognize its rela- 
tion. When a tumor is not large, it can usually be outlined by 
a hand over the abdomen and a finger in the rectum. The great- 
est difficulty is experienced when the tumor is complicated by in- 
flammatory conditions, is fixed, and often incarcerated. Tumors 



OVARIAN TUMORS. 895 

which have originated in the broad Hgament, and which He in 
close relation to the uterus, are usually less spheric and circum- 
scribed, and are less movable from their first inception. Fibroid 
tumors of the uterus and inflammatory growths of the tubes are 
likely to be confused with small ovarian cysts. These growths 
are pyosalpinx, hydrosalpinx, and hematosalpinx. The acute 
history, marked tenderness, evidence of inflammatory exudation, 
thickening, and matting together of the pelvic tissues, associated 
with marked pain, should distinguish the pyosalpinx. In hydro- 
salpinx the tumor can be movable, and may give a sensation of 
elasticity or fluctuation, but is oblong or gourd-like, rather than 
spheric. It is frequently closely adherent to the uterus, and 
affords a history of previous inflammation. A hematosalpinx is 
at first soft, then becomes hard from the coagulation of the blood. 
They are usually situated to one side of the pelvis and posterior 
to the uterus. Fibroid growths are firmer and are closely 
attached to the uterus. 

Large or Abdominal Growths. — A large ovarian cyst distends 
the abdomen, particularly at its lower part, rises abruptly from 
the pubes, and is sharply defined and generally symmetrically 
developed. Its outline, extent, and size are readily determined 
by palpation. In a large single cyst the surface will be smooth 
and regular, while in the multilocular cysts projections and irreg- 
ularities are often found. If it is made up of a large number of 
small cysts, it will be more resistant, although it will still present 
a sensation of elasticity. These gro^vths are confounded with 
pregnancy, hydramnios, extra -uterine gestation, uterine myo- 
mata, retroperitoneal growths, and the tumors of the various 
viscera of the abdominal cavity. 

Pregnancy. — The enlargement of the abdomen is more rapid 
than in ovarian tumor. It is generally associated with sup- 
pression of the menses and with the presence of such sympathetic 
nervous phenomena as nausea, vomiting, disturbed appetite, and, 
in the more advanced stage, a florid, healthy appearance of the 
patient. Suppression of the menses is not a constant symptom 
of pregnancy, for there are some women who continue to men- 
struate during the entire pregnancy, nor is amenorrhea always 
absent in ovarian growths. Error is more likely to occur in the 
unmarried, during the early stage of pregnancy. The physician 
should refrain from making a diagnosis until he has had an 
opportunity to -make a careful examination, and then should 
hesitate to express an opinion when there is the least reason for 
doubt. An examination a few weeks later will dispel the uncer- 
tainty. There is an absence of fluctuation in pregnancy; but it 
is also absent in cysts with thick, viscid contents, or in the areolar 
and glandular varieties, which are made up of a large number of 



896 GYNECOLOGY. 

small cysts. As pregnancy advances, the fetal movements, 
heart -sounds, and parts of the fetus are recognizable. The heart- 
sounds are pathognomonic of pregnancy, but are not always 
heard, owing to the position of the fetus, the large quantity of 
fluid, or to fetal death. The conjoined manipulation will afford 
information as to the relation of the enlargement to the uterus. 
Gestation in one horn of a bicornate uterus can make the diagnosis 
difficult, but a careful bimanual exploration will demonstrate the 
association of the enlargement with the uterus, and the small 
undeveloped cornu in association with the enlargement. Under 
no circumstances should the size of the uterus be determined with 
a probe when there is the least suspicion of pregnancy. 

Hydr amnios. — Hydramnios is a pathologic form of pregnancy 
in which there is a more or less large collection of amniotic fluid 
in the uterine cavity. Cases in which the collection exceeds 
two quarts have been mistaken for ovarian cysts. In large 
collections the abdominal cavity becomes greatly distended; 
its surface is smooth, white, and glistening, and fluctuation 
is very distinct. The patient suffers all the discomfort char- 
acteristic of a large cyst. The history will prove of value in 
determining the diagnosis. Hydramnios generally occurs sud- 
denly, and makes its appearance about the sixth or seventh 
month of a pregnancy which has previously run a normal course. 
Such symptoms could arise only from an ovarian cyst which 
had undergone some marked change in its nutrition, but this 
diagnosis would be excluded by the previous indications of 
pregnancy. The physical examination of such a patient will 
disclose an enlarged uterus, the cervix of which is frequently 
obliterated, os open, and covered with a dense membrane, 
through which, by manipulation, we are often able to distinguish 
parts of the fetus or obtain ballottement. Rupture of the 
membrane is followed by the discharge of a large quantity 
of water and the evacuation of the uterine contents. It should 
not be overlooked that the existence of an ovarian cyst does 
not preclude the occurrence of pregnancy, and the presence 
of the latter, by the increased flow of blood to the pelvis, may 
facilitate the growth of the cyst. As we have already seen, the 
rapidity of the growth may be so great as to require early inter- 
ference in order to save the life of the patient. Careful ex- 
amination will usually disclose an enlarged uterus either in 
front of or behind the cyst. 

Extra-uterine Pregnancy. — An ectopic gestation which has 
attained a size sufficient to permit it to be confused with an 
ovarian cyst will have presented the symptoms of early preg- 
nancy, possibly indications of rupture of the sac, and internal 
hemorrhage. Later, the tumor may be found to one side of 



OVARIAN TUMORS. 897 

or behind the uterus, and so closely adherent to it as to render 
the differentiation from it exceedingly difficult. In advanced 
stages the fetal movements and the heart-sounds may be heard. 
Vaginal palpation will disclose the fetal parts covered with 
a thin wall. After the death of the fetus other changes occur 
which render the diagnosis still more difficult. The fetus 
shrinks, becomes macerated, and the decomposition produces 
an accumulation of gas, which, with the distinct fluctuation, 
makes the condition doubly obscure. A careful analysis of 
the subjective symptoms, associated with a thorough examina- 
tion, will generally permit its recognition. 

Uterine Myomata. — Generally, the sIoav groAvth, the re- 
sistance of the tumor, and the usual presence of multiple growths, 
their irregular contour, and their demonstrable relation to 
the uterus, should afford confirmation of the diagnosis. A 
tumor which has but recently come under the observation 
of the patient, and which has, through degenerative or ob- 
structive processes, taken upon itself rapid growth, may afford 
considerable difficulty in ascertaining its true character. The 
difficulty becomes very great in edematous fibroids and in 
fibrocystic tumors. It would seem that the demonstration of 
the continuation of the mass with the cervix would be suffi- 
cient to demonstrate the uterine origin. Double ovarian cysts, 
particularly when the pedicle is short or absent, may so drag 
upon the fundus uteri as to make it apparent that the growths 
are a part of the uterus. The relation of the uterus to the 
tumor is best determined by grasping the cervix with a vul- 
sellum, which is held by an assistant; a second assistant draws 
up the tumor through the abdominal walls, while the principal, 
with one or two fingers in the rectum, and the hand over the 
abdomen, seeks the pedicle and ascertains its relation to the 
uterus. This procedure, even in double growths, will permit 
the fundus to be recognized and the nonuterine character of 
the growths to become known. In the early history of ab- 
dominal work not infrequently the abdomen was opened for 
an ovariotomy and a uterine fibroid was discovered. Indeed, 
the earlier removals of the uterus were cases of mistaken diag- 
nosis. Uterine myomata may complicate the presence of an 
ovarian cyst, and the consequent distention of the abdomen 
from the presence of two large tumors may render earlier inter- 
ference desirable. The ovarian cyst may be situated in front. 
of the myomatous uterus, and the growth may be unsuspected 
until discovered during the progress of an operation. 

Retroperitoneal Tumors. — Retroperitoneal tumors are very- 
rare. They may originate from the tissue in the pelvis or from- 
that of the subperitoneal portion of the abdomen. The more 
57 



898 GYNECOLOGY. 

fixed position of the mass, the recognition of resonance over 
the tumor, and, particularly, the ability to demonstrate, through 
rectal palpation, the presence of the rectum in front of the tumor, 
will assist in the diagnosis. 

Other Abnormal Collections and Growths.— The uterus can 
present morbid collections, such as physometra, hydrometra, 
and hematometra. Physometra is a collection of gases within 
the uterus, the product of decomposition, and is a rare con- 
dition. Hydrometra, a collection of watery fluid within the 
uterus, mostly occurs in women of advanced years, and is caused 
by retention of the secretions after obliteration of the canal. 
Hematometra is a collection of blood in the uterus, — as the 
retention of the menstrual discharges from occlusion of the 
cervix or vagina, — and it mostly occurs near puberty. In- 
spection and bimanual palpation are sufficient to disclose the 
cause. The situation of renal and hepatic cysts is sufficient 
to release them from the suspicion of an ovarian origin. 

Third, the relation of the tumor to the surrounding parts, the 
character of the pedicle, and the presence of adhesions: 

Adhesions. — The mobility of the tumor is dependent upon 
the length of the pedicle and upon the absence of adhesions. 
A tumor which can be pushed up without much dragging upon 
the uterus, be displaced from side to side, and the abdominal 
walls be recognized as sliding over it, is reasonably free from 
adhesions, and has a long pedicle. A tumor which is situ- 
ated upon one side of the pelvis, pushes the uterus to the 
opposite side, is quite immovable, or drags upon the uterus 
as it is moved, is, without doubt, an intraligamentary cyst. 
Rapid enlargement, tenderness of the abdomen, and a sen- 
sation of crepitus as the abdominal wall is being moved over the 
tumor indicate recent and extensive adhesions, the result of 
peritonitis. Limited adhesions with omentum, intestines, and 
abdominal wall can not be excluded. In very large cysts it is 
frequently difficult to diagnose the presence of adhesions. In- 
formation can often be secured by observing the respirations. 
In deep inspiration we can feel and see the upper pole of the tumor 
pushed down, unless it is fixed. The ability to drag the uterus 
down will assure its freedom. If the fundus uteri remains high 
when the bladder is empty, it is adherent. The history is valu- 
able, as adhesions occur in torsion of the pedicle, in inflammatory 
changes, and from traumatism. 

Torsion of the pedicle is recognized by the complication 
of an ovarian tumor with sudden and severe peritoneal symp- 
toms. These are severe pain in the belly, meteorism, vomiting, 
elevated temperature, rapid growth of the tumor, and tenseness 



OVARIAN TUMORS. 899 

of its surface, which indicate that the torsion has been followed 
by intracystic hemorrhage or increased exudation. 

When the patient is seen long after the torsion, the tumor 
is everywhere adherent, and the patient may show distinct 
evidences of marasmus. Sudden collapse, followed by symp- 
toms of internal hemorrhage and by peritoneal irritation, in- 
^dicate the occurrence of an internal hemorrhage. In the acute 
stages of torsion it is often difficult to arrive at a differential 
diagnosis from rupture of an ovarian cyst, peritonitis, perfora- 
tion of the stomach or intestine, renal or gall-stone colic, ileus, 
and rupture of an ectopic gestation. An attentive considera- 
tion of the history and progress of the disorder will lead to a 
direct conclusion. Inflammation of a tumor is determined by 
the accompanying symptoms. The tumor is very sensitive, 
and presents a spontaneously localized, sometimes radiating 
pain. The tumor may suddenly enlarge, or the suppuration 
may lead to the formation of gas and the development of 
a tympanitic resonance. Perforation of a suppurative tumor 
into the bladder or intestine is recognized by tenesmus and 
irritation of the bladder or by diarrhea and intestinal colic. 
Perforation is certain if portions of the tumor or its contents 
are found in the discharges. Rupture of a cyst is determined 
by the associated phenomena. Sudden oppression, suffocation, 
nausea, sometimes vomiting, diarrhea, acceleration of the 
pulse, and moderate elevation of temperature indicate the 
entrance of fluid into the peritoneal cavity. This is rendered 
more probable by marked diuresis and a perceptible decrease 
in the size of the tumor, with the presence of free fluid in the 
peritoneal cavity. The distinct tumor limits are not found, 
and there is no alteration of resonance with change of position. 

Fourth, the variety of the ovarian tumor. The glandular 
proliferating cyst is the most frequent form and attains the 
largest size. These tumors are mostly multilocular, and con- 
sequently present a less marked wave of fluctuation upon pal- 
pation. Fluctuation is an indication of the cystic character 
of the tumor, and is very distinct in the unilocular and large- 
chambered varieties. Instead of fluctuation we often find 
a kind of elasticity, which can be produced by edematous solid 
growths, and in large cysts the contents of which are made 
up of colloid or very thick, viscid material. In some cysts, 
instead of fluctuation, only a kind of vibration is determined. 
In fluctuating or tough elastic tumors which are nodular we 
will probably flnd a cystadenoma. A large fluctuating tumor 
is not necessarily a unilocular cyst, because it may contain 
within it numerous small cysts. 

Generally, a small cyst which presents no symptoms is 



900 GYNECOLOGY. 

not a cystadenoma, but may be a dermoid, a parovarian, or, 
more probable than either, a simple retention cyst of the ovary 
or' a simple serous cyst. Dermoid tumors are recognized by 
their irregular consistency — in some places soft, in others hard. 
A doughy feel has been ascribed to them, but this is rare, as 
the fatty material at the body- temperature is fluid, and it 
is only in the presence of a large amount of hair that the doughy 
sensation can be elicited. The determination that the tumor* 
had been in existence for ten or more years would justify the 
suspicion of a probable dermoid. Olshausen says that parovarian 
growths are mostly determined by their moderate size, slow 
growth, thin and relaxed walls, the translucent fluid contents, 
and the very distinct fluctuation. Parovarian tumors, as a 
rule, are spheric, though from their relaxed condition they 
may assume other forms, especially when pressed into the pelvis. 
Large cysts are generally multilocular. The presence of double 
intraligamentary growths, as well as of ascites with small tumor 
formation, is a presumption, but not a positive indication, of 
papillary grow1:hs, as the conjunction of such symptoms is found 
in all tumors. Superficial papillomata feel firm, nodular, and 
are often diffusely extended in the pelvis. In a rapidly develop- 
ing ascites, in which renal, cardiac, and hepatic causes can be 
excluded, the presence of bilateral resistance in the pelvis should 
awaken a suspicion of ruptured papillary ovarian cyst. A 
pronounced solid consistency of the growth is common to ovarian 
fibromata, sarcomata, endotheliomata, carcinomata, and terato- 
mata. 

It should not be forgotten that ascitic conditions can com- 
plicate in all these tumor formations. Ascites when present 
increases the difficulty of palpation and renders the diagnosis 
more uncertain. The fibromata and the fibrosarcomata are more 
or less nodular, of quite firm consistence, and are more frequently 
situated upon one side. Sarcomata and endotheliomata are 
generally softer. The solid carcinomata are mostly bilateral, 
quite nodular, and offer a sensation of toughness. There are no 
positive indications that a tumor is benign or malignant, as a 
cystadenoma may contain masses of cancer material. Ascites is 
generally regarded as an indication of malignancy, but it occurs 
in pseudomucin cysts, papillary growths, and with the fibromata. 
Hard consistency and an irregular surface are also reasons for 
suspicion, but are not positive indications. Early adhesion of 
the tumor, which prevents the vaginal wall from being moved 
over it, is an indication of malignancy, when abscess forma- 
tion can be excluded. 

The age of the patient is of little significance, as the age 
of puberty is inclined to the formation of cancer, and all varie- 



OVARIAN TUMORS. 901 

ties of ovarian tumor can occur at any period of life. Proper 
metastases, as distinguished from peritoneal implantation, are 
of significance, but it is not always easy to demonstrate these 
metastases, as they do not always cause symptoms, or are not 
perceptible because of the abundant ascites. In other cases 
metastases will have been discovered in the vagina, the para- 
metrium, and the rectal and peripheral lymph-glands before 
operation, fixing the diagnosis of malignancy without question. 
Pronounced cachexia and marasmus may be produced by certain 
complications, such as rupture, torsion, and inflammation; 
also in tumors of enormous size. Rapid growth, especially 
in children, speaks for malignancy. Olshausen directs attention 
to the premature edema of a leg as a symptom of cancer. 

714. Exploratory Puncture. — In obscure and complicated 
cases it was formerly the rule, before resort to operation, to 
draw off a portion of the cyst-contents for chemic and micro- 
scopic examination. The fluid may have such pronounced 
physical properties as to reveal the true character of the growth. 
The thick colloid material from proliferating cysts can be mis- 
taken for nothing else. If the fluid is serous, the possibilities 
of origin are numerous. It may have been furnished by a 
parovarian cyst, a serous ovarian tumor, a cystadenoma, ascites, 
hydronephrosis, and echinococcus sacs. In uncomplicated cases 
the fluid may possess such chemic properties as will aid in the 
differentiation, but frequently these properties are lost through 
complications, such as serous transudation and an admixture 
of blood. The fluid from a proliferating cyst is thick and colloid, 
with a specific gravity of from 1015 to 1030, and contains par- 
albumin and cylindric cells. In the papillary cysts there is 
an absence of paralbumin, while white blood-corpuscles are 
revealed by the microscope. The fluid from the Graafian 
follicles does not differ from that of the parovarian cysts. As- 
citic fluid is thin and of a light yellow or greenish color, from 
which albimiin is coagulated upon boiling, but no cylindric 
epithelium is found, and the specific gravity is from 1008 to 
1015. In the cystic fibroma the fluid is of a lemon-yellow 
color, has a specific gravity of 1020, coagulates rapidly without 
heat, and contains no cylindric epithelium. The fiuid from 
echinococcus cysts presents booklets, has a specific gravity 
of from 1008 to loio, and does not contain albumin. In 
hydronephrosis the fluid is thin, with a specific gravity of from 
1005 to 1018 ; its color varies, and it contains urea, leucin, tyrosin, 
and kreatinin. Puncture of a cyst is always attended with 
danger, and when performed in doubtful cases, for diagnostic 
purposes only, — as in the echinococcus cysts, renal tumors, 
abscesses, and dermoids, — is attended with the most serious 



902 GYNECOLOGY. 

consequences: the intestines and bladder have frequently been 
punctured; fluid may escape into the peritoneal cavity and 
cause peritonitis; or air may enter the sac and result in in- 
flammation and suppuration; a large vessel in the sac -wall 
has been injured, and a severe and dangerous hemorrhage 
has resulted. Neither chemic nor microscopic examination 
of the cyst-contents affords positive information, and the in- 
ferences thus secured do not compensate for the increased 
danger the patient undergoes. 

715. Exploratory Incision. — In cases in which we find it 
impossible to arrive at a positive diagnosis, as in tubercular 
peritonitis, in malignant disease of the ovary, tube, or omen- 
tum, or in papillary cysts, a button-hole incision, sufficiently 
large to permit the introduction of the finger, will be a far safer 
procedure than puncture, and will afford an opportunity to 
determine the condition by touch, and will permit subsequent 
drainage. It should be done under all antiseptic precautions, 
and every preparation should be made to complete the opera- 
tion if the conditions will permit. While this procedure is 
unattended with great danger, its indiscriminate practice is un- 
justifiable. It should not be utilized to secure information that 
may as well be secured by the bimanual examination. When 
the latter procedure has demonstrated an inoperable malig- 
nant condition, for instance, the incision should not be made 
merely for confirmation of the decision. 

716. Treatment. — That an ovarian cyst is not amenable 
to medicinal treatment is evident when we consider that the 
fluid is contained within a closed sac, which has its own secreting 
surface. The administration of remedies, and the application 
of counterirritants with a view to increase secretion and elim- 
ination, must be without avail. Electrolysis has had its 
advocates, but when we consider the character of these growths, 
and the danger from infection many of them must present, the 
folly of such treatment is evident. Surgical treatment should 
consist in extirpation. Puncture is but a palliative procedure 
at best, for the removal of the fluid is quickly followed by its 
reformation, and it requires more and. more frequent with- 
drawal, which proves a severe drain, through the great loss 
of albumin. As has been stated, it is associated with danger 
from the puncture of a large vessel in the tumor wall and the 
consequent hemorrhage; from the possibility of infection by 
escape of the contents of a papillary cyst or the rupture of 
so thin-walled a cyst and the escape of its contents into and 
over the peritoneal cavity; and, lastly, from septic infection. 
Puncture may be resorted to as a temporary measure in a tumor 
complicating pregnancy, when the cyst is so situated as to 



OVARIAN TUMORS. 903 

form an obstniction to labor, and then should be performed 
through the vagina, after the most thorough cleansing of that 
canal. Puncture of a cyst through the rectum, under any 
circumstances, is an unjustifiable procedure. 

717. Ovariotomv. — Extirpation of the tumor, or, as the 
operation is known, ovariotom^^ is the only operation worthy 
of consideration as applicable to all cases. Success in its per- 
formance will depend very much upon the care with which 
the diagnosis has been made, the knowledge of the operator 
as to the condition of the patient, the dexterity with which 
the operation is performed or the readiness in meeting complica- 
tions, and the judicious treatment of the patient subsequent 
to its performance. 

718. Indications. — The recognition of the danger of every 
operation upon the peritoneimi led the early operators to post- 
pone interference until the patient had begun to experience 
marked discomfort and was suffering in general health from 
the pressure of the growth. The recognition of the principles 
of antisepsis and asepsis has rendered postponement unneces- 
sary. A more careful study of the progress of the growths 
has demonstrated that it is unwise to postpone operation after 
a tumor has attained a growth sufficient to permit of diag- 
nosis, because of the various complications which can develop. 
A large proportion of ovarian tumors are of a malignant char- 
acter. Schultze places the proportion of malignancy at 27 
per cent, of all ovarian tumors; Ruge, at 15 per cent. These 
variations are dependent upon their appreciation of the re- 
lation of papillary formations to malignancy. Pfannenstiel 
found, among 400 cases in which were included parovarian 
tumors, that 19 per cent, were malignant. Reckoning the 
papillary adenomata, the number equaled 26.15 per cent. — 
a proportion that agrees with the estimates of Schultze and 
Leopold. It will be seen from these statements that about 
every fourth or fifth ovarian tumor can be considered malig- 
nant. The diagnosis of malignancy can not be made with 
certainty. If it is recognized that safety in these cases lies 
in the earliest possible extirpation, it will be evident that in 
one-half of all the cases the early extirpation of the tumor 
will be indicated. Absolutely benign growths of the ovary 
are unlimited in their size, and thus cause symptoms which 
imperil the life of the patient and lengthen the time required 
for recovery. Delay favors the development of complications 
which, if they do not threaten life, create conditions that render 
the later operation more difficult and the prognosis less certain. 
These circumstances, with the present favorable prognosis 
of ovariotomy, render it desirable that every ovarian tumor 



904 GYNECOLOGY. 

should be subjected to operation as soon as it attains a size 
sufficient to permit of its diagnosis. It was formerly advised 
to wait until the tumor had reached a size that would permit 
it to rest upon the pelvis, but no limit is now known, and the 
■operator prefers to remove the tumor as soon as the patient's 
permission can be secured. The inability to determine the 
-exact character of the growth, and the possibility of very small 
papillary tumors infecting the entire abdominal cavity, make 
early operation advisable. 

The severity of the symptoms only come into considera- 
tion b}^ promoting the early decision of the patient for opera- 
tion. The difficulties of the operation should not be a cause 
for delay, as they will not become less by waiting. The stage 
of life plays no role in the decision unless the growth is com- 
plicated by acute tubal disease, which may render temporary 
delay desirable. 

The indication for operation should be considered as urgent 
when the tumor begins to grow rapidly or when symptoms 
of threatening complications appear. Compression of the 
lungs, symptoms of uremia, of ileus, of intraperitoneal or intra- 
cystic hemorrhage, or rupture of the cyst must be considered 
as urgent and vital indications. More frequent complications 
are torsion of the pedicle and inflammation and suppuration 
of the cyst. The existence of peritoneal irritation has been 
considered as a reason for delay in operating, but now we realize 
that the patient has a much better prognosis through early 
operation than when it is delayed. 

719. Contraindications. — The reasons for withholding opera- 
tion may be transitory or permanent; the former, in severe 
complicating diseases, as intercurrent fevers, bronchial catarrh, 
especially in the aged, progressive weakness from loss of blood, 
or obstinate gastro-intestinal catarrh. The menstrual period 
is sometimes regarded as such a cause, but as it does not in- 
crease the danger of infection, it is no bar. The permanent 
contraindications are: irrecoverable disease of the heart, lungs, 
kidneys, or liver, marasmus, especially senile, and such dis- 
eases as will in a short time certainly lead to death. While 
pulmonary tuberculosis, valvular disease of the heart, and 
nephritis are contraindications, ovariotomy occasionally de- 
creases the danger from the lesion. 

Age is no contraindication, as a number of successful opera- 
tions after the age of eighty are reported. The mortality of 
100 cases operated upon after the age of seventy was 12 per 
cent. (Kelly). Ovariotomy is not contraindicated by age 
unless the tumor is associated with some disease which will 
render death certain in a short time. 



OVARIAN TUMORS. 905 

A number of anatomic contraindications were formerly 
recognized, among which were adhesions, intrahgamentary 
growths, and the existence of maHgnity. Adhesions are no 
longer considered a reason for delay, and frequently the re- 
lation of the tumor to the broad ligament is discovered only 
during the operation. In the majority of cases the attempt 
at the operation only terminates with its completion. While 
the most trifling hope of recovery exists, and no traces of cachexia 
and metastasis formation are present, the operation should 
not be considered as contraindicated. 

720. General Considerations. — Unless immediate operation 
is indicated by torsion of the pedicle, rupture of the cyst, or 
indications of cystic hemorrhage, two days should be occupied 
in the preparation of the patient, during which the pulse, tem- 
perature, condition of the respiratory organs, and urine can 
be studied. In complicated cases the procedure may be longer 
delayed, until the condition of the patient can be corrected. 
In very large cysts, with marked edema and dyspnea, many 
authors advocate a preliminary puncture, in order that the 
lungs and kidneys may have a few days to recover their 
functions before the major operation is performed. Because 
of its many disadvantages, puncture should be done very 
infrequently. For the performance of ovariotomy the follow- 
ing assistants are desirable: First, a principal assistant, who 
stands opposite the operator; second, the anesthetist; third, 
a nurse or a physician to arrange and serve the ligatures and 
sutures; fourth, a second nurse, to care for the sponges; and, 
fifth, a nurse to serve in changing the water for the hands of the 
operator and his assistant and for counting the soiled sponges. 
All these persons should be trained to know and to do their duty. 
Directions as to their preparation for the operation are given. 
(Section 178.) 

Instruments. — A knife, two pairs of scissors, two long dis- 
secting forceps, twelve small and six large clamp forceps, two 
ligature carriers, a needle-holder, an angiotribe, a trocar, a 
tube, two pairs of cyst forceps, and two short and four long 
curved needles, each threaded with a double silk loop for carriers, 
should be provided. The instruments should be carefully 
sterilized and placed in sterile trays. The patient should be 
placed upon a suitable table, with her feet toward a good light. 
An ordinary kitchen table will serve well. The operator stands 
to the patient's left and his assistant opposite. To the right 
of the operator is a table, upon which are placed the tray con- 
taining the instruments; a smaller one, for the needles and 
ligatures; and a basin with sterile water, for the hands of the 
operator, which should be changed as often as it becomes soiled. 



906 GYNECOLOGY. 

Behind the principal assistant stands another table, on which 
are two basins for the sponges or pads, and a third for the as- 
sistant's hands. The soiled sponges are collected in one of these 
basins, from which they are counted when the operation is com- 
pleted. It is important that the exact number employed during 
the operation shall be known, and that all should be accounted 
for before closing the wound. When dry sponges and pads are 
used, it is a good plan for the nurse to have a definite number, sa}^ 
twelve, placed in a basin, and no more opened until these are 
used. As the pads are withdrawn they should be placed aside 
in packages of the same number, which makes the enumeration 
of the sponges easily made and the number wanting easily de- 
termined. Want of care may result in the retention of a sponge, 
a pad, or even an instrument within the abdominal cavity, 
to the great disadvantage of the patient and to the discredit 
of the surgeon. A third table should hold the dressings, ready 
for application. There should be on hand in the room hot 



Fig. 567. — Cyst Forceps. 

and cold steriHzed water, — at least five gallons of each, — slop- 
buckets, a normal salt solution for irrigation of the abdominal 
cavity, and a suitable apparatus for hypodermoclysis or intra- 
venous injection, if the condition of the patient should demand 
it. In addition, there should be within the reach of the anes- 
thetizer a hypodermatic syringe and solutions of strychnin and 
atropin, gloinin, and antiseptic ergot. 

721. Operation. — The operation is best described by divid- 
ing it into stages and detailing the method of procedure in each 
stage. The student can thus secure a graphic outline of the 
various accidents which may possibly occur and of the expedients 
to which he will find it best to resort as he proceeds. He will 
be unlikely to mistake his course on the journey if an accurate 
chart of each portion is furnished him. 

The different stages are: 

I. The incision of the abdominal wall in the median line 
or through one rectus muscle, securing all bleeding vessels with 



OVARIAN TUMORS. 



907 



hemostatic forceps before the peritoneum is opened. (See Sec- 
tion 196.) 

2. The puncture and evacuation of the cyst. 

3. The removal of the cyst and management of the adhesions. 
(See Section 197.) 

4. The method of controlhng the circulation through the 
pedicle. 

5. The examination of the other ovary and of the general 
peritoneal cavity for bleeding vessels; the removal of all gauze 
pads. (See Section 198.) 

6. Drainage. (Sections 199, 200. 201, 202, 203.) 



gmm 




Fig. 56S. — AVall Incised; Cyst Exposed. 



7. Closure of the wound 

8. Dressing. (Section 



(Section 204..) 



205.) 

I. The Incision of the Abdominal Wall. — Great care was 
formerly exercised to open the abdominal cavity in the linea alba 
and not expose the structure of either rectus, but now I prefer 
to expose the one muscle and draw it over so that the incision in 
the posterior fascia is along its inner edge. Less hemorrhage 
thus results than when the incision passes through the structure 
of the muscle. The union resulting from the wound made 
through the Hnea alba would produce a feeble and resisting ven- 
trum. When there has been previous separation of the recti 



908 



GYNECOLOGY. 



muscles as a result of the extension, I prefer to expose both 
recti and so introduce the sutures to hold them and their apo- 
neurotic capsule in accurate apposition. The linea alba is the 
weakest part of the abdominal wall. The peritoneum is picked 
up, pulled away with two pairs of forceps from the tumor wall, 
and an incision is made through it. This avoids injury to the 
tumor wall or to a knuckle of intestine which might be situated 
over it. The peritoneum is incised the length of the wound so 
that it will not be likely to be pushed off during the subsequent 
manipulation. 

2. Puncture and Evacuation of tJie Cyst. — The incision com- 




Fig. 569. — Cyst Punctured and Being Withdrawn. 



pleted and bleeding vessels clamped, the surface of the tumor is 
explored to determine the presence of adhesions and their extent. 
They should be broken or separated to permit the exit of the 
superficial portion of the tumor. Various more or less ingenious 
trocars have been devised for evacuating the contents of the cyst. 
What is required is a cannula with a tube attached, through 
which the fluid can be carried to a receptacle beneath the table. 
The simpler and more readily cleansed this apparatus, the better. 
A glass nozle for a fountain syringe, together with three feet of 
rubber tubing, will serve very well. A glass tube of larger cali- 
ber will prove more effective when there is a large quantity of 



OVARIAN TUMORS. 909 

fluid to be evacuated, or where the fluid is very viscid. In a 
speciaU}^ prepared operating room a cannula, however, is not a 
necessary part of one's equipment, for the cyst contents can be 
readily evacuated through a knife thrust, but at the expense 
of greater soiling of, the room and clothing. 

The point chosen for puncture should be situated toward 
the upper portion of the wound, so that the contraction of 
the emptying cyst will not draw the opening within the ab- 
domen. The principal assistant should be directed to make 
pressure upon the abdomen so that the cyst as it empties shall 
be forced toward the abdominal opening and the edges of the 
cyst Avound can be seized with hemostatic or cyst forceps and 




drawn out, serving as a funnel as the cyst empties, and before 
it is completely emptied, unless flxed by adhesions, can be with- 
drawn from the abdominal cavity. When the cyst is a large 
one, I would advise that the patient be turned upon her side, 
the assistant making firm pressure to keep the cyst pressed 
into the wound as it empties. This position favors the rapid 
evacuation of the cyst contents, with the least danger of the 
entrance of the fluid into the peritoneal cavity. When the 
operator has provided himself with sterile basins, he can col- 
lect the fluid and obviate soiling of the body of the patient, 
her sterile environment, and the room with its contents. The 
lateral position also is favorable in necrotic cysts, as it permits 



910 



GYNECOLOGY. 



their removal with less soiling of the general peritoneal cavity. 
The precaution to obviate soiling the peritoneal cavity is es- 
pecially important when the cyst contents are purulent. The 
careful observations of Watkins have demonstrated that the 
contents of these cysts are often especially virulent, producing 
fatal peritonitis or other form of sepsis whenever the infection 
has found lodgment within the abdomen. Large vessels in 
the cyst wall should be avoided in making the puncture, while 
entrance of the cyst contents into the abdominal cavity can be 
still further prevented by placing gauze pads between the cyst 
and the edges of the wound. The operator, by seizing the edges 
of the cyst wound and forcibly drawing them out emptied, 
protects the peritoneal cavity from any soiling, especially when 
the patient occupies the lateral position. When a cannula is used, 
the relaxed cyst upon either side of the cannula is caught with 
suitable forceps and drawn out. In nonadherent cysts this 




Fig. 571. — Ligatures Introduced 
through Broad Pedicle. 



Fie 



, 572. — Interlacing of Sutures to 
Prevent Splitting of Pedicle. 



procedure will permit the removal of the sac, when empty, 
without any soiling of the abdominal cavity. In multilocular 
cysts the largest cyst exposed is first evacuated, through which 
succeeding cysts may be then emptied, drawing the first out to 
serve as a funnel. Areolar and derm.oid cysts are best removed 
without effort at their reduction, because the contents, es- 
pecially of the latter, are irritating to the peritoneal cavity 
and difficult to remove from it. Occasionally, the cyst-con- 
tents are so viscid that they refuse to run through the cannula. 
The edges of the puncture are seized and the sac is drawn forcibly 
against the wound, while the opening is enlarged and the jelly- 
like contents are scraped away. 

3. Removal of the Cyst and the Management of Adhesions. — In 
non-adherent cysts the tumor is already delivered, but in the 
presence of extensive adhesions its delivery may be attended with 
the greatest difficulty and the gravest peril. The aim should, as 



OVARIAN TUMORS. 911 

far as possible, be to separate old adhesions tinder the eye. Re- 
cent adhesions can frequently be separated by a sponge pad 
pressed against them as the sac is drawn out, or the hand may be 
passed into the abdomen over the tumor and thus quickly sepa- 
rate the recent adhesions. In old cases with extensive adhesions 
the conditions are different and it is unwise to separate adhe- 
sions except under sight. This purpose may require a much 
longer incision to permit of the adhesions being treated under 
the eye. The adhesions, where possible, should be torn, but where 
this is not feasible, they can be cut with scissors or knife, making 
sure that large vessels are secured. Occasionally the adhesions 
are so short or the contact so close betw^een the cyst and coils of 
intestine that the separation is impossible. The cyst wall can 
be cut through, leaving a portion attached, resembling a patch. 
Care must be exercised, however, to remove all secreting sur- 
faces from the lining membrane of the cyst. Great care must be 
exercised in separating old adhesions, as large vessels in the 
omentum, mesentery, and pelvis may be torn, producing severe 
and even fatal hemorrhage. Injuries to intestines, bladder, 
spleen, and liver may occur, and if overlooked, produce fatal 
results. When the tumor has been delivered its pedicle, if suf- 
ficiently long, should be clamped and the mass removed. A 
hasty glance is then given to the condition of the viscera where 
dense adhesions have been separated, to make sure that adhe- 
sions have not occurred which will cause serious hemorrhage or 
permit the soiling of the peritoneal cavity with the contents of 
intestine or bladder. If the pedicle is long and thin, a ligature 
may be thrown around it and tied. The stump should be folded 
under in order that it shall not form adhesions with the coil of 
intestine. 

4. Management of the Pedicle. — In a short, broad pedicle this 
is not feasible, but the section method, illustrated by Figs. 571, 
572, and 573, serves an excellent purpose. 

When tied in several sections the ligatures should inter- 
lace, in order to prevent the pedicle from splitting, and the peri- 
toneum should be sutured over the stump. This procedure takes 
additional time, but will often save the patient from very uncora- 
fortable if not dangerous adhesions between the stump and in- 
testine. The Downes electric angiotribe affords an excellent 
method of securing against hemorrhage, and leaves the w^ound with- 
out the irritation of a foreign body. In a cyst without a pedicle the 
sac should be enucleated and the vessels secured as the operation 
proceeds. These cases present some of the most trying problems 
within the realm of abdominal surgery. In cutting away the 
tumor the precaution must be exercised to provide a sufficient 
button to prevent the ligature from slipping. If a ligature 




912 GYNECOLOGY. 

slips on a short, broad pedicle, the parts spread out, the vessels 
retract, and serious hemorrhage occurs, which may be difficult 
to control. Sometimes, when the pedicle has been ineffectually 
tied, the ovarian or uterine artery slips back and forms a hema- 
toma in th^ stump, which so fills up the tissues as to make 
sufficient traction upon the ligature to withdraw the tissue 
and permit a fatal hemorrhage to follow. The tendency of 
the tissue external to the ligature to shrink after the removal 
of the tumor should not be forgotten, and when the traction 
is severe, a second ligature may be judiciously placed behind 
it to secure the ovarian artery. Silk, wire, and animal ligatures 
have been employed for securing the pedicle. Silk, from its 
strength, ease of preparation, and small amount of material 
required, is most frequently employed. I prefer the chromic 
catgut, but the precaution must be exercised to tie it tight 

and to leave a secure 
button, because of its 
greater propensity to 
slip. Other methods of 
securing hemostasis have 
been employed : the ves- 
sels have been twisted; 
Fig- 573- — Sutures Interlaced and Tied. for many years the pedi- 
cle was brought out of 
the wound and clamped ; Keith applied a temporary clamp and 
charred the tissues with the hot iron ; Skene improvised a set of 
electrocautery clamps, by which the tissues were slowly burned 
through and the application of the ligature avoided. This appa- 
ratus has been greatly improved and made practicable through 
the ingenuity of Dr. A. J. Downes, of this city. 

5. The next step was formerly described as the toilet of the 
peritoneum. Unless evidence of hemorrhage makes it incum- 
bent to secure bleeding vessels, the next procedure should be to 
inspect the other ovary. Not infrequently it will be found the 
seat of disease, often completely involved by a glandular, papil- 
lary, or dermoid growth. Where necessary, it must be removed, 
but, if possible (unless in mature women), a portion of the organ 
should be saved. The deprivation of the possibility of procrea- 
tion is too serious a matter in young women to justify the need- 
less sacrifice of ovarian structure. In many cases, even when 
associated with large tumors, a portion of the ovary capable of 
performing all the functions of that organ can be saved. Where 
adhesions have existed the omentum, mesentery, and pelvis 
should be carefully inspected for bleeding vessels, and any such 
should be secured. Wherever possible the peritoneum should 
be sutured over torn and denuded surfaces, clots of blood removed. 



OVARIAN TUMORS. 913 

and ragged edges left from adhesions cut away. Should oozing 
occur from a large surface, it may be controlled by infiltration of 
the tissue with i to 4 of a i : 1000 solution of adrenalin chlorid 
with sterile normal salt solution through a hypodermatic syringe. 
Should this procedi^re be ineffectual and the surface too large to 
permit it to be quilted together with a continuous catgut suture, 
a gauze pack can be employed. The pack has an additional ad- 
vantage in extensive denudation that it keeps the intestines 
from contact with the raw surface until the peritoneum has had an 
opportunity to reform and thus prevents the redevelopment of 
firm adhesions. It is true, the packing becomes walled off, but 
the adhesions thus formed are soon absorbed after the removal 
of the gauze, unless the patient has become infected. The end 
of the pack can be brought out at the lower angle of the wound, 
but the drainage is against gravity, frequent dressing of the 
wound is required, the danger of infection is increased, and a 
weakened ventrum results in an increased susceptibility to sub- 
sequent hernia. For these reasons it is preferable that the end 
of the drain be carried into the vagina and the gauze be ultimately 
removed through that canal. Drainage by the vagina presup- 
poses that the vagina has been sterilized as a preliminary to the 
operation, but should this have been neglected, the gauze pack- 
ing may be placed in the pelvis and the wound closed, making an 
incision through the posterior vaginal vault, which can easily be 
done for its removal. All wounds penetrating the intestine or 
bladder should be sutured as soon as discovered in order to pre- 
vent the peritoneal cavity from being soiled by their contents. 
Wounds in the peritoneum should be, as far as possible, sutured. 
When the omentum has been torn, making a ragged, stringy mar- 
gin or opening in its structure, it should be ligated and the por- 
tions external to the ligature be excised. Otherwise a coil of 
intestine may slip through such an opening or beneath a band 
and become strangulated. The peritoneal cavity should be 
cleansed of blood and cyst contents, preferably by sponging with 
dry gauze, but when there are large denuded surfaces, or the peri- 
toneum has been soiled with irritating fluids as from a dermoid or 
suppurating cyst, it should be irrigated with normal salt solu- 
tion and should be closed filled with the solution. The fluid per- 
mits the intestines to float, allows the regeneration of the denuded 
epithelium, and lessens the danger of unfortunate adhesions. 
As a final consideration before closing, the surgeon should be 
certain that the abdominal cavity contains no foreign material, 
such as gauze pads or instruments. Directions have been given 
for keeping tab upon the number of pads used and of insuring 
the certainty of their removal. The surgeon should not rely 
wholly upon the nurse, but should be certain that he has removed 
58 



914 GYNECOLOGY. 

all the sponges he has inserted. It is a very good plan first to 
wall off the intestines with a long and wide piece of gauze and 
place the smaller pieces, when necessary, below it. 

6. Drainage. — This subject is no longer granted the import- 
ance in abdominal work it was vouchsafed when I first began the 
practice of surgery. Then the profession gave heed to the 
admonition of Tait: "When in doubt, drain." Experience has 
taught the wonderful power the peritoneum possesses of protecting 
itself, and, outside of a vaginal wick, drainage is rarely employed. 
The gauze wick has supplanted the glass drainage-tube. Twenty 
years ago I frequently introduced the glass drain, but have not 
used one in several years. In extensive denudation of the pelvic 
peritoneum associated w4th oozing the gauze tampon is of value. 
In repair of the large intestine in its lower portion, especially 
where the tissues sutured are more or less friable from inflam- 
matory changes, it is wise to cover the surface loosely with gauze 
in order to aft'ord a vent should union fail and a fecal leak occur. 
The gauze drain, when possible, should open into the vagina 
and be removed through it. The drain should be permitted to 
remain from four to six days. 

7 . Closure of the Wound. — The aim of the operator is to so close 
the wound that like surfaces shall be brought in apposition, and 
afford as little opportunity as possible for the accumulation of 
fluids (serum or blood) in the wound. After prolonged obser- 
vation of different methods I have chosen the procedure described 
in Section 204 as the most satisfactory and the least likely to be 
followed by hernia. The one flaw in this procedure is the possi- 
bility of serum or blood collecting between the peritoneum and 
muscle and its infection from its proximity to the intestinal canal. 
Should the patient after operation have a continuous elevation 
of temperature for which no explanation is apparent, it will be 
wise to make a puncture to ascertain the existence of an extra- 
peritoneal collection. Its early evacuation saves a weakened 
ventrum. 

8. Dressing. — The wound dressing should be simple and 
unirritating. The wound surface should be free from patho- 
genic germs and be protected from them until recovery has fol- 
lowed. The silkworm-gut sutures are left long, the wound is 
sponged with 50 per cent, alcohol in sterile water, then covered 
lightly about the suture ends with gauze, then several layers of 
gauze, and finally a pad of wood cotton and gauze held in place 
with pieces of plaster to which tape is attached to be tied over 
the dressing. The whole dressing is then secured by a Scultetus 
binder. This method of securing the dressing affords easy ac- 
cess to the wound and with but little annoyance to the patient. 

General Considerations. — The study of the differential diag- 



OVARIAN TUMORS. 



915 



nosis of ovarian tumors should have prepared the operator 
to appreciate the fact that, after the most careful investigation 
of his cases, he must not infrequently expect to meet with con- 
ditions entirely different from those which the physical signs 
have indicated. AVhat appears a simple ovarian cyst will pre- 
sent complications that will test the ingenuity of the most 
experienced operator to overcome. The inexperienced operator 
should prepare himself for every emergency, and should have 
previously planned for them, as the prudent general plans 
for the coming battle. The more carefully the case has been 
studied, the patient prepared, and the emergencies anticipated, 



oH 



LIGATURE 
ONOi/AR!AN 



9 f,^ 







OP*, 



,r 



Fig. 574. — splitting of Pedicle when Sutures are Tied without Interlacing. 



the more certain will be the success. It is far better to 
go to unnecessary preparation many times than to be un- 
prepared once. Patients with large ovarian cysts frequently 
suffer from pressure symptoms, and are greatly benefited by 
previous purgation, stimulation of the secretion of. the kidneys 
and skin, and the administration of strychnin and atropin 
to strengthen the action of the heart and vessels. In the in- 
cision care is exercised to avoid pushing off the peritoneum 
and to escape injuring the bladder, a loop of intestine, or the 
cyst. The bladder may be drawn up to a higher level by ad- 
hesions to the cyst. It is recognized by the arrangement of the 
muscle-fibers in its wall. The parietal peritoneum is occasion- 



916 GYNECOLOGY. 

ally inseparable from the surface of the tumor along the line 
of incision, when the cyst may be opened and emptied before 
proceeding to the separation of the adhesions. 

The intestine is rarely in danger of injury during this stage 
of the procedtire, but occasionally a loop may be situated in 
front of the cyst. 

The toilet of the peritoneum should not be understood 
to mean thorough drying of the cavity; indeed, much spong- 
ing and manipulation of the peritoneum are injurious and favor 
the formation of adhesions. The cavity is most readily cleansed, 
and with the least injury, by irrigation with normal salt solu- 
tion. The retention of a considerable quantity of the fluid 
is beneficial, in that it favors peristalsis, and by its absorption 
replenishes the liquid waste. Ragged omentum and shreds 
or bands of adhesions should be removed. When the irrigating 
fluid continues to come away bloody, careful examination 
should be instituted to ascertain the source of the bleeding. 
The abdomen must not be closed while a considerable quantity 
of blood is being lost. Unless the abdomen has been soiled 
with infective cyst contents it is better not to irrigate. If 
the precaution has been exercised to protect the cavity by 
gauze packing, irrigation will be very infrequently required. 
A saline solution is probably the least irritating of anything 
that can be introduced into the peritoneal cavity, but even it 
handicaps to some degree the functions of this extensive ab- 
sorbing surface. 

Post-operative Treatment. (Sections 206-220.) 

722. Incomplete Operation. — The conditions in which the 
operation has not been completed are most frequently those 
of intraligamentary parovarian cysts, and particularly papil- 
lary cysts. The structure of the broad ligament is more or 
less involved, and not infrequently adhesions affect a large 
portion of the intestine. The more experienced the operator, 
the less frequently will the incomplete operation be performed. 
With judicious measures, cases in which the operation can 
not be completed are exceedingly rare. In the intraligamentary 
variety an incision of the peritoneum, where it is situated about 
the base of the tumor, is made, the tumor is drawn up, form- 
ing a pedicle, and the tissue is pushed off by blunt dissection. 
Sometimes the tumor may be opened and an incision made at 
its base, by which the sac is then dissected out. Frequently 
it is advisable to precede the operation by ligation of the larger 
vessels, particularly the ovarian arteries, after which the dis- 
section can be accomplished with less hemorrhage. Adhesions, 
when in the form of cords and bands, can be cut with the Paquelin 
cautery. In the papillary variety it is very important that the 



OVARIAN TUMORS. 917 

mass should be removed, even if it is necessary to extirpate 
the uterus to accompHsh it. Frequently what seem desperate 
cases recover when the original source of the disease is removed, 
even though extensive infection of the peritoneal cavity has 
occurred. When adhesions are very extensive and the condi- 
tion of the patient is such as to preclude the possibility of com- 
plete removal of the sac, its cavity should be emptied, cleansed, 
and sutured to the parietal peritoneum of the abdominal wall, 
while the remaining portion of the wound is closed. The sac 
cavity is packed with iodoform gauze. Thus it may be kept 
open, irrigated from time to time with disinfectant solutions, 
and the packing renewed until the cavity fills by granulation. 
This procedure is necessarily attended with increased danger 
to the patient, as it is impossible to keep such a wound com- 
pletely aseptic. 

When a tumor is deeply situated in the pelvis, the abdominal 
opening may be closed after an incision has been made through 
the base of the tumor into the vagina, through which the end 
of the gauze packed into the cyst may be carried. Over this 
gauze the cyst-wall is closed, and covered, when possible, with 
peritoneal flaps. Intraligamentary tumors are sometimes pushed 
up into the mesentery, and the removal of the mass necessitates 
the ligation of important branches of the mesenteric artery. 
When a large portion of mesentery is thus ligated, the vitality 
of the portion of intestine supplied by it is endangered and 
gangrene of the gut may result. Such cases may demand 
the excision of the affected portion of the intestine and an end- 
to-end anastomosis. In metastasis of the papillary variety 
into the omentum, forming, as it frequently does, good-sized 
masses involving the entire omentum, the latter should be 
removed after ligation of its base with a number of catgut liga- 
tures. It was my privilege, in a patient who had double-sided 
papillary ovarian cysts, with extensive ascites from the infected 
peritoneimi, and who had been subjected three times to ab- 
dominal section for the evacuation of this fluid, to remove 
both ovaries and the greater part of the uterus after an exten- 
sive dissection. The entire omentum was also removed. This 
patient, in whom the dropsical effusion had previously collected 
so rapidly tha.t they were unable to get her out of bed after 
operation before the fluid had reaccumulated, had no recur- 
rence of effusion subsequent to the complete operation, and 
two years later was in good health. 

723. Rupture of the Cyst. — In cysts of the glandular variety 
which have been greatly distended, or when the pedicle is partly 
twisted, the cyst- wall becomes fragile and is easily torn, per- 
mitting its contents to escape into the abdominal cavity. This 



918 GYNECOLOGY. 

accident is not a serious one unless the cyst contents have 
undergone degeneration, as in suppurating cysts, or are irritat- 
ing in character, as in the dermoid and papillary varieties. Tear- 
ing the cyst-wall will necessitate a thorough irrigation of the ab- 
dominal cavity to neutralize or to remove the contents. 

724. Hemorrhage. — The site of the hemorrhage will greatly 
influence its character. In large cysts with extensive adhesions 
hemorrhage may take place from the cyst-wall or from vessels 
that have been torn within its walls and threaten a fatal re- 
sult. The adhesions should be separated rapidly, the cyst 
raised, and its pedicle secured to cut off the blood-supply. The 
larger and more vascular adhesions should be separated between 
ligatures or clamp forceps. If the hemorrhage threatens life, 
the assistant may place his hand within the abdomen, com- 
press the abdominal aorta, and maintain the pressure until 
the operation is completed. Such a procedure prevents the 
further supply of blood, and so arrests the bleeding. Hemor- 
rhage may occur from a very extensive surface, particularly 
when malignant disease has been the subject of removal, or 
extensive papillary growths which are intraligamentary or be- 
hind the uterus. Fatal syncope and death may follow the 
removal of very large tumors as a result of decreased ab- 
dominal pressure. The vessels relieved from pressure become 
distended by the blood, and form extensive reservoirs, by which 
so much of the blood is withdrawn from the circulation as to 
cause cerebral anemia and the death of the patient. Such 
a patient can be said to have bled into her own vessels. Such 
an occurrence is likely to take place only in very large tumors, 
and may partly be obviated by emptying the cyst slowly. When 
syncope occurs, the head should be lowered, and an assistant 
may compress the abdominal aorta with the hand in the ab- 
domen, while the treatment of the pedicle and the toilet of 
the abdomen proceed. Occasionally, it may be necessary to 
remove the uterus on account of the free bleeding from its 
torn and denuded surfaces. The vitality of the patient may 
be maintained by hypodermatic injections of strychnin, gr. -gV^iV 
hourly or every two hours, a i : 1000 solution of adrenalin chlorid, 
gtt. x-xv every hour, atropin, gr. y-^, to contract the blood- 
vessels, ergone, nxxx, or a hypodermoclysis of normal salt solu- 
tion. The salt solution can be poured directly into the abdominal 
cavity while the patient is in the Trendelenburg posture, or trans- 
fused directly into a vein. The latter measure affords an in- 
creased quantity of fluid by which the vessels can be filled and the 
heart have something upon which to contract. 

725. Visceral Injuries. — Injuries to the intestine are possible 
during complicated operations. In making the abdominal 



OVARIAN TUMORS. 919 

incision it is important that the peritoneum should be raised 
with forceps and a small opening made, to prevent not only 
injury of the cyst- wall, but of a possible loop of intestine which 
may be adherent over it. With the opening, the incision in 
the peritoneum can be extended the full length of the external 
wound by holding 'it up and incising it under the eye. In very 
dense adhesions the intestines may be torn into, or even across, 
during the progress of the operation. When such a lesion 
occurs, the parts should be carefully repaired at once, and 
measures should be taken to prevent soiling the peritoneal 
cavity with the bowel-contents. The intestine should be care- 
fully sutured, and when torn through to such a degree as to 
render its vitality uncertain, resection should be done and an 
end-to-end anastomosis made. This procedure is accomplished 
very quickly with the Murphy button or one of the mechanical 
devices for holding the ends of the divided gut, especially the 
O'Hara forceps. In the absence of these instruments, the 
anastomosis may be performed by first suturing the mesenteric 
surface of the bowel by a single suture, another just opposite 
to this, and then one on each side between the first two. This 
divides the bowel into four sections, each section of which can 
be rapidly closed by continuous suture. The needle is passed 
through the loop of these sutures at every other insertion, which 
prevents puckering and contraction of the lumen of the bowel. 
The first row of sutures should be covered by a second, and this 
also covers over the sutures we have employed to maintain 
the ends together. A still better procedure is to introduce 
an interlocking continuous suture from the mucous membrane 
side of the bowel, and superimpose this by a similar suture 
in the peritoneal covering. Such a closure is rapidly accom- 
plished and very effective. The closure can be made with 
fine silk or chromic catgut, or the internal may be made with 
the former and the external (or peritoneal) with the latter. 

The most difficult cases for suture are those in which the 
rectum has been torn low down in the pelvis. Portions of 
the bowel may be so devitalized that they will not subsequently 
hold, and a fecal fistula follows. In all cases in which the in- 
jury of the bowel has been extensive, and its condition endan- 
gered, the parts should be packed with iodoform gauze, which 
affords a vent in case union is not complete. Complete closure 
of the wound should be interdicted, because the patient would 
develop a dangerous peritonitis before the occurrence of rup- 
ture is recognized. The position and relation of the ureter 
should be kept in mind in tumors situated low in the pelvis, 
or in those which are developed in the broad ligament, and 
particularly in the papillary forms of ovarian growth, as the organ 



920 GYNECOLOGY. 

may be pulled up or torn off in the enucleation of such masses. 
When the tumor is so situated as to endanger the injury of the 
ureter, it is better to dissect out the latter to make sure that 
it is uninjured. When it has been cut or torn, the preferable 
procedure is to establish an anastomosis between the divided 
ends. (Fig. 234.) If this is impracticable, then transplantation 
into the bladder should be performed. If the ureter is so short 
as to cause its vitality to be endangered by the necessary trac- 
tion, to reach the bladder the latter should be anchored to the 
side of the pelvis in a position most favorable to relieve the 
tension. The ureter may be introduced into the descending 
colon or an attempt may be made to introduce its end into 
the ureter of the opposite side; but one should hesitate in at- 
tempting the latter, as failure means the imperiling of the un- 
affected kidney and ureter. Its end may be brought out through 
the ;skin and a urinary fistula established, but this means 
an ^exceedingly uncomfortable condition for the patient. One 
alternative is to ligate the ureter, which should be done with 
double ligature, as a single ligature is likely, under the process 
of absorption, to become loose and permit a subsequent leakage 
of urine. The urine is secreted until the pressure from the 
distended pelvis is equal to that of the blood-pressure, when 
secretion no longer occurs. The organ unused becomes atrophied. 
Another alternative is the extirpation of the kidney, and, be- 
fore attempting this, the operator should be well satisfied that 
the kidney on the opposite side is capable of doing the work. 

The bladder may be injured during an operation. It may 
be drawn up over the anterior surface of the tumor and be 
incised, or its fundus may be removed before its true character 
is suspected. The peculiar interlaced muscular structure of 
the bladder-wall should permit its recognition. When it is 
opened or injured, it should be sutured. In a case of fibroid 
tumor in which it was my misfortune to cut away the entire 
summit of the bladder the walls were sutured, and the patient 
recovered. In such cases it is important that the bladder 
should be watched to prevent it becoming unduly distended 
during the convalescence. It should be frequently evacuated 
in order to avoid separation of weak union and leakage of urine. 

726. Prognosis. — The result of the operation of ovariotomy 
will depend greatly upon the manner in which it has been con- 
ducted. With the exercise of every precaution, there will 
frequently be cases of delayed convalescence, owing to latent 
or preexisting pathologic conditions; but the danger is greatly 
increased when the operation has been carelessly performed 
and its details imperfectly practised. The operator and his 
assistants should have been so well trained that no deviation 



OVARIAN TUMORS. 921 

from the proper course, even though sHght, will be overlooked. 
What avails the most rigid cleanliness of person, room, and 
instruments when a ligature is employed that has been dragged 
over blankets or unclean tables before its introduction? when 
the wound is dusted with iodoform from a box that has been 
standing open, and has been used in all sorts of cases about 
a ward? when the operator rubs his nose, scratches his head, 
or touches nonsterilized objects, and introduces the hand into 
the abdominal cavity without precautionary cleansing? Such 
indiscretions are often responsible for stitch abscesses and 
other septic processes. Pus-collections and cellular inflamma- 
tions in the pelvis in the region of the uterus frequently result 
from infection of serous collections in Douglas' pouch. Ele- 
vation of temperature, rapid pulse, and abdominal tender- 
ness subsequent to the fourth or fifth day should lead to care- 
ful exploration for their origin. A mass of exudate in the 
pelvis should be considered an indication for vaginal incision, 
for the administration of salines until free purgation is secured, 
and for the use of rectal and vaginal enemas of hot water 
at least twice daily. The vaginal incision should be a free 
one across the vault of the vagina, after which the cavity should 
be thoroughly irrigated with normal salt solution and a good 
packing of iodoform gauze introduced. This procedure should 
be preceded by careful sterilization of the vagina. 

727. Intestinal Complications. — In difficult operations in- 
flammatory intestinal sequels are not infrequent. The in- 
testines may be obstructed by twists, and this danger is ag- 
gravated by bands of inflammatory adhesions, or by openings 
in the omentum or mesentery, through which a knuckle of 
intestine can slip and become strangulated. Lacerations of 
the intestinal coat affect the peristaltic action, and may lead 
to paralysis of a section, with ensuing symptoms of obstruction. 
A twist or volvulus may become so fixed that nothing will 
pass it. In walls that are already weakened a fecal fistula will 
result. In a case some years ago in the Philadelphia Hospital 
an operation by a colleague was followed five weeks later by 
symptoms of obstruction, and the patient vomited stercoraceous 
material. The abdomen was reopened and five feet of intestine 
were torn up, disclosing a distinct volvulus, which was untwisted, 
when the patient recovered after a prolonged convalescence. 
The importance of an early reopening of the abdomen in such 
a case can not be overestimated, as the obstruction may be 
due to strangulation of a knuckle of intestine beneath inflam- 
matory bands or to its inclosure between sutures of the wound. 
The latter is unlikely to occur when the wound is closed in the 
manner we have suggested. 



922 GYNECOLOGY. 

• 

728. Causes of Death. — Causes of death after ovariotomy 
are, as in hysterectomy, shock, hemorrhage, and peritonitis. 
These sequels are much less infrequent, however, as the opera- 
tion for ovariotomy is more easily accomplished and the dura- 
tion is shorter than in hysterectomy. Tetanus, which for- 
merly occurred frequently after ovariotomy, is now extremely 
rare. Ileus may occur in the second week as a result of ad- 
hesions or twists of the intestine. Inability to accomplish 
the evacuation of the intestine by injections with the pelvis 
elevated, and especially when complicated with stercoraceous 
vomiting, should require the reopening of the abdomen. The 
mortality of ovariotomy is very slight — much less than formerly.' 
This is partly due to the fact that operations are now performed 
early, and it is only in rare instances that the patients are sub- 
ject to the deleterious action of . the cyst. Early operation, 
before the patient experiences complications, is attended with 
very slight mortality. Thus, Martin, in more than 1000 ovari- 
otomies, has but 2 per cent, mortality; Olshausen reported his 
last 100 ovariotomies with onjy 4 deaths. The uncomplicated 
ovariotomy has practically no mortality. 



LIST OF AUTHORS QUOTED 



Abel, 50, 55, 637, 757 

Abrahams, R., 251 

Adams, 530 

Ahlfeld, 584 

Albarran, 642 

Alexander, 496, 528, 530, 533, 549 

Alquie, 531 

Amann, 848, 854, 855 

Amussat, 234 

Andrews, 67, 68, 69, 73, 317 

Antal, 720 

Apostoli, 149, 150, 151, 152, 153, 701, 

703. 704 
Aran, 430 
Arnold, 103 
d'Arsonval, 153 
Atlee, 708 
Auvard, 244, 245, 741 



B. 

Baccelli, 391 

Baer, 46, 724 

Baker, 785 

Baldwin, 235 

Baldy, 498, 536 

Bandier, 638 

Bandler, 586 

Barbour, 169 

Bardenheuer, 274, 649, 801 

Barnes, 17, 19, 225, 596 

Barrows, 392 

Bartholin, 75, 167, 330, 333, 335, 339, 

352, 366, 629, 633, 634 
Bassini, 532 
Baum, 249 
Bayle, 651 
Beatson, 142 
Beclard, 245 
Belfield, 215 
Bensa, 650 
Bernhardt, 825 
Bernutz, 430 
Biegel, 665 
Biffi, 91 
Billroth, 792 
Bischoff, 314, 316 
Bishop, E. Stanmore, 275, 276, 653, 

718, 728, 733, 734, 737 



Bissell, 536 

Bizzozero, 74 

Bland, P. Brooke, 115, 621, 745 

Blau, 760, 761 

Bode, 649 

Boeckman, 108 

Bohmer, 55 

Borelius, 811 

Bottini, 792 

Bouilly, 734 

Bovee, 250, 496, 543, 546, 549, 790, 

795 
Bozeman, 268 
Braun, 784 
Breisky, 343, 344 
Bright, 19 
Brum, 70 
Bullitt, 859 
Bumm, 65 
Burnham, 723 
Burrage, 514, 544 
Byford, 176, 181, 357 
Byrne, 156, 784, 785, 796 

C. 

Cabot,_7p, 87, 88, 89 

Calderini, 792 

Camero, 372 

Carlo, 881 

Cassati, 533 

Chadwick, 23 ^ 

Chantreuil, 783 

Charcot, 78 

Cheston, 596 

Chrobak, 824, 825 

Churchill, 146, 257 

Clark, J. C, 128, 191, 371, 455, 795, 801 

Cleveland, 312, 313 

Cohnheim, 664, 764, 841, 878 

Cohnstein, 783 

Colpe, 384 

Coover, E. H., 142 

Coplin, 53, 56, 57, 60, 63, 68, 77, 91, 653 

Corneuil, 402 

Corradi, 793 

Corson, E. R., 271 

Coste, 157 

Courty, 16, 19, 20, 559 

Cowper, 167, 339 

Cox, S. E., 633 



923 



924 



LIST OF AUTHORS QUOTED. 



Cred^, 80 1 

Cucca, 824 

Cullen, 745, 746, 748, 756, 760 

Cumston, 123, 828 

Curran, 250 

Curry, 63 

Czerny, 787, 790^ 792, 793, 796, 811 



DaCosta, John C, 639 

DaCosta, John C, Jr., 78, 79, 80, 89, 
90 

Dare, A., 82 

Davidson, 104, 258 

Deaver, 29, 160, 161, 166, 171, 172, 
173, 196, 204 

Delafield, 56 

Depage, 230 

Deschamps, 459, 539, 540, 785 

DeSinety, 183, 382, 394, 401 

Dickinson, 257 

Doderlein, 61, 62, 65, 348, 349, 375, 
629 

Doleris, 74, 533 

Doran, Alban, 854, 855, 861, 877 

Douglas, 74, 199, 201, 417, 419, 443, 
444. 445. 447. 451. 453. 463, 470. 500, 
514, 516, 550, 562, 564, 565, 566, 577, 
603, 619, 638, 676, 717, 726, 729, 730, 

731. 732, 733. 769. 785. 792, 793. 795. 

797, 798, 800, 807, 809, 811, 813, 819, 

879, 921 
Downes, A. J., 156, 463, 797, 911, 912 
Doyen, 717, 731, 732, 733, 736, 738, 

792, 852 
Drszewczky, 829 
Ducrey, 70 

Dudley, A. P., 312, 313, 314, 325, 535 
Dudley. E. C, 497, 498, 499, 512, 513, 

514. 549. 728 
Duhrssen, 545, 794 
Duke, A., 322, 325 
Dunning, 236, 398, 609, 616 
Duret, 532 
Duverney, 339 
Dybowski, 760 



E. 

Eastman, Joseph, 460, 797, 801 
Edebohls, 24, 42, 46, 49, 50, 259, 408, 

532, 709, 790 
Edgar, 62, 72 
Ehler, 823 

Ehrlich, 78, 79, 80, 81 
Eiselsberg, 641 
Ellinger, 45 
Emmet, T. A., 143, 259, 281, 308, 309, 

310, 312, 325, 326, 383, 408, 439, 495 
Etheridge, no 



F. 

Farre, 187 

Fenwick, 879 

Ferguson, ss^ 2>h 275. 276 

Ferguson, A. H., 496, 536, 540 

Ferraresi, 231 

Finsen, 74, 155 

Fisher, J. M., 236, 600, 604 

von Fleischl, 82 

Fleiss, 220 

Flemming, 54 

Flick, 364 

Fowler, 456 

Fraipont, 824 

Franck, 796 

Frankel, 73, 214, 215, 823 

Freund, W. A., 71, 306, 308, 432, 497, 

546, 550, 787, 799, 800, 829 
Friedlander, 69 
Fritsch, 321, 324, 354, 401, 645, 646, 

792. 793. 814, 823, 826, 827 
Frommel, 769, 796, 798, 813, 814 
Furbringer, 109 



Gabbett, 365 

Gabritschowsky, 80 

Gant, 195 

Gariel, 268, 560 

Garrigues, 299, 303, 495 

Gartner, 191, 622, 629, 637 

Gehrung, 490, 491, 703 

Gersterberg, 572 

Gessner, 841 

Gilliam, 496, 536, 538, 539, 540, 549 

Goldman, 757 

Goldspohn, 533, 534 

Gooch, 400 

Goodell, 39, 41, 46, 824 

Gottschalk, 546, 715 

Gow, 724 

von Grafenberg, 784 

Gram, 64, 66, 69, 73, 341 

Grawitz, 70 

Greenhalgh, 609 

Gremlier, 638 

Grenach, 53 

Gross, 544 

Griibler, 58 

Gubarroff, 801 

Guerin, 209 

Guit6ras, Ramon, 337 

Gusserow, 653, 666, 766, 771, 840, 

842^ 
Guthrie, 192 
Guyon, 362, 372 



Haeser, no 

Haine, no 

Hare, Hobart A., 133 



LIST OF AUTHORS QUOTED. 



925 



Harrington, Chas., 109 

Harris, 56, 57, 96, 317, 364, 373 

Hart, 169 

Hegar, 106, 299, 303, 346, 495, 640, 

705, 706, 718, 784, 785, 786, 809, 

810, 894 
Heidenhain, 816 , 

Heinecke, 810 
Heller, 343 
Hennig, 185, 187 
Heppner. 304, 307 
Hermann, 54, 195, 783 
Herr, 281 

Herzfeld, 808, 809, 811 
Hewes, 79 

Hewitt, Grailey, 490, 491, 510 
Hicks, Braxton, 609 
Higbee, 39 

Hildebrandt, 302, 303, 306, 346 
Hirst, 562 

Hochenegg, 806, 809, 811, 812, 813 
Hodge, Lenox, 525, 527, 532 
Hoffman, 491 

Hofmeier, 651, 665, 720, 766, 816 
Holden, 628 
Hollander, 230 
Houston, 196 
Houzel, 825 
Howe, 250 
Huguier, 167 
Hunter, 651 

J. 

Jacobi, 544 
Jacobs, 459 

James, 609 

Jenner, 79 

Johnson, J. Tabor, 651 

Johnstone, 217 

Jones, Mary Dixon, 869, 877, 878 

Joulin, 609 

Julien, 360 

Julliard, 89 

Jung, 53 

K. 

Kahlden, 841, 855 

Kaiserling, 59 

Kaltenbach, 793, 798, 815 

Kalteyer, 78 

Kappes, 435 

Keen, 71 

Kehrer, 826 

Keith, 125, 134, 451, 912 

Kellar, 848 

Kellogg, 703 

Kelly, Howard, 94, 95, 96, 109, 371, 

541, 727, 737, 793, 795, 801, 904 
King, 610 
Kiwisch, 400 
Klebs, 72, 637, 649, 765 



Klebs-Loeffler, 72 

Klob, 400, 651, 854, 858, 

Kobelt, 167, 875 

Koeberle, 723, 795 

Koch, 68 

Koch, J. H., 74 

Kocher, 810 

Konig, 201 

Koppe, 629 

Korff, 117 

Kraske, 637, 806 

Kronig, 61, 62, 349, 722, 804 

Krusen, 584 

Kuchenmeister, 47 

Kuhn, 801 

Kummel, 875 

Kundrat, 804 

Kiister, 658 

Kiistner, 123, 562, 806, 881 

L. 

Labarraque, 112 

Landau, 284, 465, 466, 717, 767, 792, 

Langenbeck, 790, 796 

Langhan, 744 

Lauenstein, 178, 270, 289, 290, 297, 

301, 306, 322 
LeBec, 725 
Le Clerc-Dauday, 372 
Lefour, 693 
Lembert, 455, 725 
Leopold, 209, 665, 792, 815, 816, 817, 

824, 877, 903 
Levy, 71, 810 
Lewers, 766, 854 
Lieberkuhn, 195, 197 
Liebmann, 793 
Lindfors, 544 
Lisfranc, 14 
Littre, 177 

Luschka, 176, 187, 199, 200 
Lustgarten, 71 
Lutaud, 371 -^ 

M. 

Mackenrodt, 545, 792, 795, 803, 816, 

Maguire, 392 

Mann, 181, 372, 534, 545, 667, 699 

Mano, 73 

Marchand, 832, 834 

Marcy, 560, 724 

Maritan, 859 

Marmorek, 390 

Mars, 343 

Marsh, 370 

Martin, A., 69, 305, 308, 313, 316, 344, 

384, 639, 720, 729, 801, 825, 827, 

829, 842, 922 
Martin, C., 213, 730 
Martin, Franklin, 149, 532, 543, 701, 

715. 716 



926 



LIST OF AUTHORS QUOTED. 



Matthews-Duncan, 430 

Maydl, 813 

Mayo, Charles H., 70 

Mayo, William, J., 70 

McBurney, 373 

McCosh, 455 

McGannon, 273 

Menge, 61, 62, 349, 722, 805 

Meyer, 70 

Mickwitz, 881 

Mikulicz, 89, 127, 128, 792 

Milieu, 91 

Mitchell, S. Weir, 411, 429 

Moller, 665, 666 

Monsell, 337 

Morgagni, 191, 195, 853, 859, 861 

Mosetig-Moorhof, 825 

Muir, 66 

Miiller, 4, 157, 158, 224, 226, 230, 231, 

232, 235, 326, 584, 595, 622, 637, 

859, 861 
Miiller, Peter, 651, 793 
Munde, 255, 256, 490, 525 
Murphy, 919 

N. 

Naboth, 9, 28, 183, 256, 257, 377, 378, 

380, 383, 512, 746, 778 
Napier, 215, 217 
Nauss, 693 
Neisser, 65, 66, 350 
Nelson, 39 
Neugebauer, 637 
Newman, 532, 797 
Nilson, 106 
Nitze, 94 

Noble, Charles P., 311, 499, 601, 833 
Noble, George H., 321 
Noeggerath, 400 
Northrup, 116 
Nott, 38, 39 
Nourse, 513, 515 
Nuck, 159, 168, 232, 340, 624, 625 

O. 

O'Hara, 919 

Olshausen, 541, 544, 666, 792, 793, 814, 

816, 822, 900, 901, 922, 
Orth, 56 
Orthmann, 70 
Osier, 70 
Outerbridge, 311, 3: 



;i2 



P. 

Paget, Sir James, 844 

Pankau, 89 

Paquelin, 384, 645, 647, 795, 801, 821, 

824, 916, 
Pawlik, 94, 795 
Parsons, 704 



Pean, 458, 717, 796 

Peter, 343 

Petit, 89 

Pfannenstiel, 71, 836, 870, 903 

Pfliiger, 188, 231 

Pick, 53, 834 

Plouquet, 873 

Poirier, 817 

Polk, 199, 699, 802 

Poupart, 168, 201, 208, 373, 434, 435, 

438, 531. 582, 611, 623 
Powell, S. D., 370 
Pozzi, 44, 106, 114, 163, 228, 246, 266, 

626, 781, 853, 858 
Pratt, 46, 50 
Price M., 594 
Prochownik, 584, 665 
Pryor, 26, 65, 546, 727, 737, 760 

R. 

von Recklinghausen, 664, 852 

Reed, C. A. L., 68, 514 

Reed, E. L., 633 

Reich, 793 

Rein, 212 

Reverdin, 130 

Reyburn, 766 

Riberts, 764 

Ricard, 824 

Richelot, 733, 796 

Ricker, 841 

Ries, 496, 536, 760, 802 

Ristine, 320, 321 

Ritchie, 66, 853 

Robb, 103 

Roberts, 68 

Robertson, 221, 610 

Robinson, 347 

Robinson, Byron, 720 

Rokitansky, 642, 854, 863 

Rontgen. 149, 154, 155 

Rosenmiiller, 186, 191, 857, 859, 861 

Rosthorn, 70, 804 

Royster, 250 

Ruge, 350, 394, 752, 839, 841, 903 

Rumpf, 801 

Rydygier, 720, 810 

S. 

Sanger, 67, 266, 281, 319, 320, 326, 
687, 792, 815, 826, 853, 854, 856, 
858 

Sanger-Barth, 853, 855 

Sappey, 181, 183 

Sauter-Recamier, 790 

Savage, 166, 170, 175, 176, 179, 193, 
203, 205, 206, 207, 208, 210 

Saxonia, 221 

Scanzoni, 400, 408, 879 

Scarpa, 435 

Schaefer, 431 



LIST OF AUTHORS QUOTED. 



927 



Schaeffer, 152 

Schatz, 792, 798 

Schauta, 717, 733, 760, 792, 804, 811 

Schede, 285, 809, 812 

Schering, 53 

Schiff, 220 

Schlange, 810 * 

Schleich, 119 

Schmidt, 544 

Schnabel, 873 

SchneiderHn, 117 

Schramm, 825 

Schroder, 158, 178, 262, 263, 384, 399, 

408, 637, 652, 658, 697, 720, 723, 

769, 784, 785. 786, 793, 803, 845 
Schuchardt, 794 
Schiicking, 545, 648 
Schultze, 381, 432, 522, 523, 524, 525, 

527, 825, 903 
Schwarz, 765 
Seehg, 757, 758, 786 
Sehgman, 341, 343, 852 
Segond, 459 
Semm.ehveis, 387 
Sherrington, 81 
Shimer, A. B., 735, 736 
Shober, John B., 700 
Shoemacher, 665, 666 
von Siebold, 775 
Siegelman, 63, 73 
Simon, 33, 42, 284, 785 
Simon-Hegar, 297, 301, 325 
Simpson, Alexander, 321, 322, 323 
Simpson, F. F., 538, 549 
Simpson, Sir James Y., 35, 400, 549, 

609, 699 
Sims, Marion, 23, 24, 25, -^^^ 40, 41, 

42, 171, 235, 257, 265. 269, 346, 380, 

492, 503. 512, 522, 705, 797, 806, 

823 
Skene, 75, 92, 94, 156, 163, 177, 192, 

355' 356, 357. 629, 912 
Skoldberg,_384 
Skrobanski, 251 
Smith, Albert H., 490 
Smith, Greig, 607 
Smith, Heywood, 382 
Smyly. 777 
Snow-Beck, 402 
Spaeth, 69 

Spiegelberg, 777, 877 
Spohn, 859 
Steinthal, 811 
Sternberg, 65 
Stiegel, 633 
Stilling, 825 
Stimson, 123 
Stoltz, 494, 495, 550 
Strassman, 216 
Stratz, 774 
Stroganoff. 61 
Sutton, J. Bland, 190, 213, 618. 651, 

854, 873 



Taenzer, 58 

Tait, Lawson, 318, 319, 321, 326, 582, 

914 
Talley, F. W., 39 
Tallqvist, 82 
Tannen, 815 
von Tauffer, 792, 806 
von Teuffel, 793 
Thiersch, 764, 766, 816, 825 
Thoma, 80 
Thomas, 379, 384, 490, 510, 525, 560, 

710 
Thompson, 643 
Thorn, 815 
Thornton, 880 
Thure-Brandt, 14*7 
Tilt, 346 
Toisson, 81 
Torggler, 822, 826 
Tracy, S. E., 833 
Tratz, 639 
Trendelenburg, 23, 26, 273, 452, 454, 

646, 724, 734, 799, 918 
Treves, 440 
Tuffier, 119, 797 
Tuholske, 585 
Tyson, 569 



Ungara, 824 
Unna, 70 



U. 



V. 



Van De Warker, 785, 823 

Van Geison, 57 

Veit, 752, 793, 801, 834 
, Vineberg, 545, 549 

I Virchow, 400, 430, 642, 683, 764, 766, 
775, 841, 868 

Von Hacker, 114 

Vulliet, 48, 571, 825 



W. 

Walcher, 270, 274 

Waldeyer, 188, 751, 764 

Walsh, Joseph, 364, 365 

Walthard, 349, 350 

Wassiljew, 650 

Watkins, 910 

Webster, 536, 607 

Wecchi, 792 

Weigert, 58 

Weil, 842 

Welch, 745 

Wells, Spencer, 100 

Werder, X. O., 285, 802 

Wertheim, 66, 545, 760, 804, 811, 814 

Westermark, 806 

White, 116 



928 



LIST OF AUTHORS QUOTED. 



Widal, 388 

Wiggins, 498 

Williams, W. Roger, 745 

Williams, J. Whitridge, 61, 62, 815, 841, 

von Winckel, 231, 652, 665, 693, 766, 

767, 774, 794, 812 
Winter, A., 198, 749, 796, 816, 617 
Wolff, 637 
Wolffier, 810 



Wright, 79, 91 

Wyder, 188, 216 

Wylie, W. Gill, 512, 533, 534, 545 



Zeiss, 64 

Zuckerkandl, 810, 813 
Zwank, 490, 491 

Zweifel, 62, 350, 724, 798, 811, 829, 
852 



NDEX 



A. 



Abdominal binder, 406, 697 
examination, 96 
section, 114 

assistants in, 120 
details of procedure, 452 
site of incision, 121 
Abortion, 328, 402, 585, 887 
incomplete, 676 
tubal, 585, 588 
Abscess about appendix, 22 

collection in pelvis from appendix, 

443 

from Bartholin's gland, 340 

intraperitoneal, 442 

stitch, 788 

tubo-ovarian, 420 

vulvar, 335, 339 
Acarus scabiei, 73 

Accidents and results of fistula opera- 
tions, 287 
Acetanilid, 133, 140 
Acetate of lead, 143 
Acid, acetic, 53 

boric, 140, 143, 370, 637 

carbolic, 104, 106, 133, 143, 336, 337, 
343> 361, 382, 383, 399, 400, 630 
633. 70s. 707. 822 

chromic, 146, 382, 399, 630 

gallic, 569, 572, 699 

hydrochloric, 146 

hydrocyanic, 343, 360 

lactic, 384 

muriatic, 105, 106 

nitrate of murcury, 146, 382, 399 

nitric, 146, 630, 824 
fuming, 145, 399 

oxalic, 106, 370 

picric, 57 

pyroligneous, 258, 827 

salicylic, 359, 384, 637, 825 
and pepsin, 824 

sublimate 106, 143 

sulphuric, 146, 407, 699 
dilute, 572 

tannic, 146, 569, 572 
Acne, 332 

Adenocarcinoma of uterus, 749, 752 
Adenomata of uterus, 622 
Adenomatous cysts, 869 
59 



Adenomyoma, 852 
Adenosarcoma, 840 
Adhesions, 124, 410, 739, 898 

in displaced uteri, 523, 533 

in ovarian tumors, 881, 883, 884, 
898, 915, 918 

indication of malignancy, 900 

of abdominal tumors, 898, 910 

vascular, 124 
Adipocere, 596 
Adnexa, suppurative inflammation of, 

152 
Adrenalin, 142 
Agents, deodorizing, 112 

various local, 145 
Albumin in cyst contents, 871 

peptone, 871 
Albuminuria, 887 

Alcohol, 53, -108, 323, 342, 630, 705, 
777, 792, 825, 914 

absolute, 792, 825 

dilute, 648 
Alcoholic preparations, 119 
Alexander operation, 530 

advantages of, 533 

disadvantages of, 533 
Alkaline solutions, 337 

waters, 353, 368, 406 
Alteratives, 141, 147 
Alum, 143, 572 

and sugar, 630 
Alumnol, 337, 
Amenorrhea, 18, 149, 152, 214, 217, 

403, 424, 668, 674, 675, 880, 895 
Aminoform, 360 
Ammonium benzoate, 370 

chlorid, 141 

salts, 699 
Amputation of the cervix, 261, 492, 

784 
Amyl nitrite, 100 
Anal ulcerations or fissures, 27 
Anastomosis of intestine for gangrene , 

917. 
for injury, 919 
of ureter with bladder through ab- 
domen, 285 
through vagina, 284 
Anatomy and embryology of the 
genito-urinary organs of the woman, 
156 



929 



930 



INDEX. 



Androgyna, 244 
Anemia, 16, 141 
Anesthesia, administration, 117 
agents employed in, 115 
bromid of ethyl, 115 
chlorid of ethyl, 115 
chloroform, 115, 116 
ether, 115, 116 
nitrous oxid gas, 115 
artificial respiration in, 118 
contraindications to, 118 
indications for, 115 
local, agents employed in, carbolic 
acid, 118 
cocain, 118, 632 
ether, 118 

ethyl chloride spray, 118 
freezing, 118 
infiltration, 119 
nervous, 15 

scopolamin-morphine, 117 
spinal, 119 
Angiosarcoma, 839 
Angiotribe, 462, 463, 791, 797 
Anodynes, 135, 147, 427 
Anorexia, 362, 827 
Anovulvar fistulae, 290 
Anteflexion of uterus, 506 
cellulitis a cause, 508 
diagnosis, 509 

differential from myoma, 509 

rectal palpation in, 509 
etiology, 50& 
immobile, 508 
indifferent, 508 
mobile, 508 
pathologic, 508 
physiologic, 508 
symptoms, 508 
treatment, 509 
bougies, 512 
laminaria tents, 511 
operative methods, 512 
Anteposition of uterus, 500 
Anteversion of uterus, 501 
diagnosis, 502 
etiology, 502 
symptoms, 502 
treatment, 502 
cincture, 504 

dilatation and curetment, 503 
hot douches, 502 
massage, 504 
Sims' operation, 503 
Antipyretics, 439, 827 
Antipyrin, 828 
.Antisepsis, 102 

of cervix and uterine cavity, 113 
Antiseptics, 143, 382, 851 
Antispasmodics, 141 
Anus, anatomy of, 195 

columns of Morgagni, 195 
sinuses of Morgagni, 195 



Anus, artificial, 799, 813 

fissure of, from pressure of uterus, 

506 
orifice of, 195 
Aperients, 450 
Apiol, 142 

Aponeurosis, union of, 129 
Apoplexy of the ovary, 191 

ovarian, 567 
Appendages, displacements of, 564 
diagnosis, 565 
symptoms, 565 
treatment, 566 
instrumental, 566 
operative, 566 
Appendiceal inflammation, 98 
Appendicitis a frequent cause of peri- 
tonitis, 443 
catarrhal, 372 
Appendix vesiculosa, 191 
Applications, antiseptic, 145 
astringents, 146 
blisters, 144 
caustic, 146 
counterirritants, 144 
croton oil, 144 
external, 144 
ice-bag, 144 
local, 145 

pepsin and salicylic acid, 824 
tinct. iodin, 146 
various agents, 145 
carbolic acid, 145 
Churchill's tincture, 146 
creasote, 146 
iodoform, 146 
nitrate of silver, 146, 371 
nitric acid, 146 
Arbor vitae, 158, 183 
Areolar cysts, 869 
Argonin, 337 
Argyrol, 145, 337, 399 
Aristol, 114, 827 
Arrangement for operation, 120 
Arsenic, 141, 381, 407 
Artery, azygos vaginae, 202 
circular, of cervix, 202 
inferior hemorrhoidal, 204 
internal iliac, 202 
internal pudic, 201 
middle hemorrhoidal, 202 
of bulb, 206 
of clitoris, 205 
ovarian, 201 
puerperal, 202 
superficial perineal, 204 
transverse perineal, 204 
uterine, 201 
vaginal, 201 
Artificial heat, care in use of, 132, 

135 
Asafetida, 141, 222 
Ascaris lumbricoides, 74 



INDEX. 



931 



Ascites, 662, 687, 872, 880, 890, 893, 

900 
Asepsis, 102 
Aspiration, 10 1 
Aspirator, 10 1 
Assistants, 114, 905 

operator and, 120, 905 > 
Astringent douches, 143 
Astringents, 143, 145, 337, 382, 383, 

529> 569. 572, 648, 827 
Atmocavisis, 573 
Atresia, acquired, 237, 264 

congenital, 237 

diagnosis of, 238 

influence on menstruation, 238 

lateral, 240 

treatment of, 238 

of cervix, 399 

of genital canal, 237 

of one horn of uterus, 227 

of urethra and vagina, 246 

site of occurrence of, 237 

symptoms and signs of, 237, 238 

vaginal, 264 

vulvar, 237 
Atropin, 100, 116, 119, 135, 139, 

915 
Auscultation, 99 
Autoinfection, 348 

B. 

Bacilli coli communis, 68, 90, 329, 

441 
Bacillus aerogenes capsulatus, 72 

anthracis, 90 

coli communis, 90 

diphtherias, 72 

influenz£e, 90 

leprae, 90 

mallei, 90 

of cocain, 360 

of Doderlein, 61 

pestis, 90 

pyocyaneus, 72 

tetani, 90 

tuberculosis, 90 

typhosus, 71, 90 
Bacteremia, 90 
Bacteria found in blood, 90 
Bacteriologic cultures, 63 

bacilli coli communis, 68 
bacillus tuberculosis, 68 
gonococcus, 65 
staphylococcus pyogenes aureus, 

63 
streptococcus pyogenes, 64 
Bacteriology of genital tract, 60 
Balloon, rubber, for vesical disease, 

371 
Bandages, elastic, 489 
Barium platinocyanid, 154 
Bartholinitis, 339 



Bartholinitis, diagnosis, 340 

treatment, 340 
Bartholin's gland, 339 
description of, 167 
Baths, 143 

cold hip, 406 

hot hip, 359 

medicated, 406 

peat, 548 

sand, 548 

sitz, 143, 353, 426, 548, 826 
Battery, electric, 150 
Bed-sores, 826 
Belladonna, 369 
Benzin, 107 

Benzoate of ammonium, 268, 359, 
370 

of sodium, 359 
Bicycle, 142 
Bifidities, 224 

degrees of division, 224 
Bimanual procedure, 30 
Binder, Scultetus, 914 
Bischoff's dissection, 316 
Bismuth salve, 827 

subgallate, 337 

sub nitrate, 337 
Bladder, 192 

anatomy of, 192 

bas-fond of, 192 

catheterization of, 95 
double catheter in, 96 

dissected from cervix in vesico- 
uterine fistulas, 281 

divisions of, 192 

duplication of, 248 

exploration of urethra, ureters and, 

91 
exstrophy of, 241, 246 
extension of cancer to, 751, 769 
inflammation of, 92 

of neck of, treatment, 369 
injury to, during operation, 920 
irrigation of, 568 
mucous membrane of, 193 
position of, 192 
trigone of, 192 
tumors of, 622, 642 
carcinoma, 649 
symptoms of, 649 

of villous tumors simulated 
b}^ uterine cancer, 649 
treatment of, 649. 
dermoid, 643 
myomata, 643 
cystic, 643 
diagnosis of, 643 

differential, between renal and 
vesical hemorrhage, 644 
significance of character of, 
hemorrhage in, 644 
hard, 643 
symptoms of, 643 



932 



INDEX. 



Bladder, tumors of, myomata, symp- 
toms of, anemiia, 643 
cachexia, 643 
cystitis, 643 
emaciation, 643 
hemorrhage, 643 
pain, 643, 645 
treatment of, 645 

incision, abdominal, 645 
high bladder, 645 
suprapubic transverse, 645 
vaginal, 645 
operation, the, 645 

means of controlling hem- 
orrhage in, 647 
removal through urethra, 
644 
poh^pi, mucous, 642 

villous, 642 
total extirpation of, 650 
Blastoma, 832 
Blister, 144, 426 
Blood, changes, 76 
coagulation, 91 
composition of, 82 
culture, 90 
examination of, 76 
plaques, S^, 85 
plasma. 82 
Bloodletting, 144 
Borax, 146 
Boric acid, 143, 146 
Boroglycerid, 147, 258 
Bougies, Hegar's, 706 

in the ureters, 801 
Bovinin, 134 
Brandy, 451 

Broad ligaments, 197, 856 
cysts of, loi, 856 
echinococcus, 857 
parovarian, 857, 875 
defects of round or, 231 
fibroma of, 858 

confounded with epiplocele, 858 
with fatty hernia, 858 
with ovarian hernia, 858 
lipomata of, 858 
malignant growths of, 858 
parovarian varicocele, phleboliths, 
858 
Bromid salts, 141, 370 

of ethyl, 115 
Bruit, 99 
Buboes, 336, 636 
Buchu, 370 
Bulb of the vestibule, 167 

of the ovary, 207 
Bulbocavernosus muscle, 167, 192, 292, 
346 

C. 

Cachexia, 643, 671, 672, 842, 844, 901 
Caesarean section, 829 



Caffein citrate, 133 
Calcification in cyst walls, 887 
Calcium chlorid, 699 
phosphate, 83 
tungstate, 154 
Calculi and concretions following fis- 
tula operations, 288 
Calculus, renal, 369, 479, 568, 884 
passage of, 357 
uterine, 683 
Calomel, 133, 141, 337, 451 

and sodii bicarb., 133 
Camphor, 360, 648 
Canal of Gartner, 191 

of Nuck, 159, 168, 625 
Cancer of uterus, 649 
Cannabis indica, 141, 
extract, 698 
fluid extract, 141 
tincture, 342 
Cannula, glass, 112 
Carbohydrates, 699 
Carbol-xylol, 53 

Carbolic acid, 104, 106, 133, 143, 336, 
337' 343. 361, 382, 383, 399, 400, 
630, 705, 707 
Carcinoma, 649. 678, 744, 751, 849, 858 
circumscribed, 753 
classification of, 744 

anatomic, 744 
clinical forms, 762 
dissemination of, 756 
method of extension, 744 
of bladder and ureters, 649, 751 
of Fallopian tube, 855 
of ovary, 877 
of uterus, 744, 849 
of body, 752 

adenocarcinoma of, 752 
histology of, 754 
microscopic examination in 

diagnosis of, 753 
necrosis of, 754 
process of extension, 753 
rarity of, 752 
of cervix, 749 

adenocarcinoma of, 749, 752 
frequency of, 745 
methods of development, 744 
of extension, 744 

blood-vessels slow to be in- 
volved, 757 
cauliflower grovv^th, 746, 749, 

.763 
clinical forms, 762 
cylindric cell, 745 
influence upon surrounding 

tissues, 746, 749 
involvement of bladder and 
ureters, 751 
of other organs, 751 
process of extension, 747, 756 
general, 744 



INDEX. 



933 



Carcinoma of uterus, methods of inva- 
sion of vagina from, 758 
lymph-vessels principal route 

of extension, 756, 758 
squamous cell, 745 

development of, 746 
histology of, 748 
structure of stroma, 747 
complications of, 773 
myoma, 773 
ovarian tumors, 773 
periuterine inflammation, 773, 

774 
pregnancy, 773, 774 
diagnosis of, 775 
curet, 776 

differential, from chorioepithe- 
lioma, 780 
from chronic cervical catarrh 

with laceration, 778 
from necrosis of fibroid poly- 
pus, 778 
from papillary erosion, 778 
from partial retention of pro- 
ducts of conception, 779 
from sarcoma, 780 
from syphilitic ulceration , 

.7 79 

laminaria tents, 776 

microscopic examination, test 
excision for, 777 

rectal examination, 777 
duration, 781 

of recovery, 814 
effect of, upon pregnancy and 
labor, 782 

pregnane}^ and labor upon, 782 
etiology, 764 

Cohnheim's theory, 764 

condition of life, 766 

heredity, 766 

Klebs' bacillus, 765 

origin from micro-organisms, 

765 

Ribert's theory, 764 

sex, 766 

sexual activit3^ 766 

Thiersch's theory, 764 

Virchow's theor}^, 764 

Waldeyer's theory, 764 
glandular involvement, frequencjr 

of, 760 
physical signs, 772 
prognosis, 782 
recurrence of, 760 
symptoms, 767 

amyloid degeneration of large 
glands, 772 

cachexia, 767 

degeneration of kidney, 770 

dilated ureters, 769 

distention of hemorrhoidal 
veins, 770 



Carcinoma of uterus, symptoms, edema 
of lower extremities, 770 
of vulva, 770 
and clinical course, emaciation, 
771 
hemorrhage, 767 
hydronephrosis, 769 
lung embolism, 771 
metastasis, 770 
obstruction of veins and 

arteries, 770 
offensive discharge, 768 
pain, 768 
pleurisy, 771 
pneumonia, 771 
sacculated kidney, 770 
sepsis, 770 
treatment, 783 
in labor, 829 

in pregnancy complicating, 829 
operation in, 829 

Csesarean section in, 829 
inoperable cases, 818 
caustics, 823 
cureting, 819 

danger and injuries in, 8 1 9 
dry, 826 

gauze packing, 821 
local, 826 

palliative operations, 819 
parenchymatous injections, 

825 
suture cureted surface, 825 
symptomatic, 827 
when disease far advanced, 

827 
with fistula of rectum and 
bladder, 827 
operable cases, 783, 784 
extirpation, total, 786 
by hysterectomy, ab- 
dominal, 799 
control of hemorrhage 



m, 802 
Freund's 



operation, 



in marked involve- 
ment of the cervix, 
801 
modifications of, 801 
by hysterectomy, vagi- 
nal, 790 
accidents of, 797 
by perineal method, 8 1 3 
by sacral method, 806 
catheterization of ure- 
ters, 795 
clamp forceps in, 792, 

796 
comparative advan- 
tages of abdominal 
and vaginal routes, 
805 



934 



INDEX. 



Carcinoma of uterus, treatment, oper- 
able cases, extirpa- 
tion by hysterecto- 
my, vaginal, contra- 
indications to, 806 

control of bleeding 
vessels, 795 
of bleeding vessels 
by hot iron, 795 

deep vaginal incision 
in, 794 

difficulties in, 794 

disposition of ovaries 
and tubes, 791 

injuries to bladder, 

797 
injuries to one or both 

ureters, 798 
injuries to rectum, 798 
modifications of, 792 
mortality of, 814 
nonemployment of 

forceps or ligatures, 

797 
Schuchardt's opera- 
tion, 794 
treatment of the 
wound in, 791 
possibilities of reinfec- 
tion, 787 
uncertainty of keeping 
outside the disease, 

787 . 
when it may be under- 
taken, 787 
partial operations, vaginal 
784 
amputation of cervix 
with galvanocau- 
tery loop, 784 
Hegar's operation, 784, 

785 
Schroder's operation, 

784, 785 
preliminary, 790 
recurrence, after opera- 
tion, 815 
diagnosis of, 817 

extension to parame- 
trium, 816 
infection, 817 
lymph-gland, 817 
metastatic, 818 
lymph-glands source of 
redevelopment, 817 
summary, 830 

abdominal operation, 8^ 1 
vaginal operation, 831 
Card index system, 59 
Cardialgia, 710 
Carmin, 53, 56 

Caruncle, urethral, 27, 346, 626 
Carunculse myrtiformes, 167, 243, 346 



Castor oil, 451 

Castration for my omata, 718 

uterine, 458, 718, 729 
Cataphoresis, 150 
Catarrh, chronic cervical, 375, 778 

intestinal, 152 
Catgut, 129, 130, 724, 919 
for ligatures, 107 
juniper, 724 
Catheter, double, 96, 114 
glass, 139 

precautions in use of, 355 
self-retaining, 355 
ureteral, 95 
Catheterization, 139, 643 

microbes introduced by, 362 
of the ureters, 92, 364, 568 
Caustics, 146, 823 
acid, carbolic, 145 
chromic, 146 
hydrochloric, 146 
nitrate of mercury, 146 
nitric, 146 
sulphuric, 146 
caustic iron, 146 

potash, 268 
chlorid of zinc, 146 
creasote, 145 
liquid, 146 
silver nitrate, 146 
soda, 53 
Cauterization, 824 

for fistula, 268 
Cautery, galvano-, 636, 647, 795, 796 
loop, 792 

Paquelin, 647, 795 
thermo-, 636, 647, 790, 830 
Celloidin, 55 

Cellulitis, abscess from hypogastric 
glands, 432 
cause of ante version, 502 

of atrophy of uterus and ovaries, 

432 
of dysmenorrhea and sterility, 432 
of lateral version, 506 
diagnosis, 436 
differential, 437 

hematoma of broad ligament, 

437 
myoma of uterus, 437 
pelvic peritonitis, 437 

division of, 430 

etiology of, 432 

pelvic parametritis or periuterine 
phlegmon, 430 

physical signs, 433 

abscess resulting from, 432 
diffuse pelvic suppuration, 6^6 
pathologic anteflexion, 432 

prognosis, 438 

duration and progress, 438 

symptoms, 433 

treatment of, 438 



INDEX. 



935 



Cellulitis, treatment of, diet, 439 
douches, hot vaginal, 439 
pelvic massage, 440 
preventive, 438 
surgical interference, 439 
utero-sacral, 432 

Cervix, amputation of, s6i, 492 
after-treatment, 263 
antisepsis of, and uterine cavity, 

113 

areolar hyperplasia of, 379 

carcinoma of, 748 

changes of, 180 

chronic catarrh of, 375 

cystic degeneration of, 377 

divisions of, 178 
infra vaginal, 179 
supravaginal, 179 

double flap, 262 

for areolar hyperplasia, 379 

for bilateral laceration of, 378 

for follicular erosion of, 378 

single flap, 262 
erosion of, 376 

follicular, 378 

granular, 376 

simple, 376 
hypertrophic elongation of, 474, 

483 
incision of, 46, 708 

complete bilateral, 47 
inflammation of, 375 
causes of, 379 
classification of, 374 
diagnosis, 380 
physical signs, 380 
prognosis, 381 
symptoms, 379 
treatment, 381 

constitutional, 381 
electrical, 384 
local, 381 
surgical, 384 
lacerations of, 254, 378 
diagnosis, 255 
S3^mptoms, 255 
sarcoma of, 836 

split in vesico-uterine fistula, 281 
Chancre, 636 
Chancroids, 334, 636 

organism of, 63 
Change of life, 221 
Charcoal in malignant disease, 637 

with iodoform, 826 
Charcot's bodies, 78 
Chemotaxis, 87 
Chloral, 133, 135 
Chlorid of calcium, 699 
Chlorin water, 827 
Chloroform, 115, 116 

and oxygen, mixture of, 117 
in gl^'cerin, 343 
Chlorosis, 16, 879 



Chlorosis, cause of delayed menstrua- 
tion, 213 
Cholesterin, 871 
Chorea, 215 
Chorioepithelioma malignum, 744, 780, 

832,850 
Chromxium trioxid, 382 
Churchill's tinct., 146, 257 
Cinchona, 407 

Cincture for anteversion, 504 
Cinnamon, tincture of, 572 

water, 133 
Clamp forceps, 792, 796 

objections to use of, 461, 852 
Richelot's, 796 
Clay pad electrode, 151 
Cleansing hands, 108 
Cleveland's suture in laceration of 

perineum, 313 
Climacteric, delayed, in fibroid 
growths, 695 
discharge following, 22 
entire removal of Fallopian tubes 
to establish, 718 
Clitoris, 159, 161 

anatomy of, 161 

bifid, 246 

defects of, 241 

hypertrophy of , 27, 241 

nervous phenomena produced by,. 

242 
prepuce adherent to, 242 
treatment of, 242 
Cocain, 118, 343, 360 
Coccyx, resection of, for artificial anus^ 

641 
Codein, 45, 828 
Cod-liver oil, 407 
Coition, 13, 161, 165, 167, 251 

a cause of inflammation, 332 

in diseased appendages, 565 

loss of sensation, 15 

painful, 565 
Cold pack, 141 ^ 

Colic, gall-stone, 899 

intestinal, 372, 899 

renal, 899 

uterine, 145, 400 
Collapse, 885, 899 

atropin in, 451 

digitalin in, 451 

external heat in, 451 

strychnin in, 451 
Collection of specimens for examina- 
tion, method of, 77 
Collodion, 152 

Colloid contents of cysts, 901 
Colon, malignant disease of, 98 
Color index, 83 
Colostomy, 641, 813 
Colpeurvnter, 268, 801 
Colpitis,' 348, 818 
Colpocleisis, 278, 806 



936 



INDEX. 



Colpocleisis, methods of procedure in, 
279 
objections to, 279 
Colporrhaphy, anterior, resection of an- 
terior vaginal wall for, 495 
Stolz's sutures in, 494 
posterior, 495 
Coma, 771 

Comfort of patient, post-operative, 132 
Communications, abnormal, 249 
recto-vaginal, 249 
recto-vagino-vesical, 250 
suprapubic opening of vagina and 

urethra, 250 
vagino-rectal, 250 
vesico-vaginal, 250 
Commutator, 151 
Compresses, cold, 343 
Compression of the lung, 904 
Compressor urethrae, 192 
Condylomata of vulva, 630 
Connective tissue, distribution and re- 
lations, 200 
pelvic, 200 

two varieties of, 200 
Constipation, 17, 406, 670 

with cancer, 828 
Copaiba, 360 
Copper, sulphate of, 146 
Copremia, 17 
Copulation, 212, 223 
Corpus albicans, 191 
luteum, 190, 214 
cysts of, 863 
of pregnancy, 190 
nigricans, 191 
Corpuscles, counting the, 80 
Cotarnin hydrochlorate, 569 
Cotton, absorbent, 146, 337 

pack, 354 
Counterirritants, 144, 407, 426 
Cover glasses, 77 
Cowper's gland, 167, 339 
Crayons, chlorid of zinc, 146 
iodoform, 146 
silver nitrate, 340 
sulphate of zinc, 146 
Creasote, 146 
Creolin, 112, 143 
Croton oil, 144, 426 

mixture, 407 
Cubebs, 360 

Culdesac, utero-rectal, 199 
vesico-uterine, 199, 200 
Curet, 258, 790, 825 
douche, 51 

perforation of uterus with, 254 
sharp, 820 
spoon, 825 
Curetment, 503, 705, 819 

method of, 705 
Cystadenoma, 900, 901 
Cystalgia, 364 



Cystitis, 361, 643, 644, 884 
acute, 361, 567 

character of urine in, 362 

constitutional disturbances in, 362 

etiology of, 361 

symptoms of, 362 
chronic, 363, 567 

condition of urine in, 363 

constitutional conditions in, 363 

cystotomy for, 372 

diagnosis of, 363 

from administration of certain 

drugs, 362, 367 
from foreign bodies, 362,367 

etiology of, 361 

hematuria in, 363 

symptoms of, 363 
membranous, 366 

causes of, 366 

symptoms of, 366 
of gonorrheal origin, 363, 366 
pathologic changes in, 362 
prognosis in, 367 
treatment of, 368 

calculi and foreign bodies, 367 

irrigation of bladder, 370 

medical, 368 

prophylactic, 368 

surgical, 372 
tubercular, 363 
Cystocele, 27, 295, 478 
diagnosis of, 481 

treatment. See Colporrhaphy, an- 
terior. 
Cystoscope, electric, 94, 156 
Cystoscopy, 644 
Cystotomy, 372 
Cysts, adenomatous, 869 
areolar, 869 

of Bartholin's gland, 339 
treatment of, 340 

of broad ligament, 10 1, 856 
echinococcus, 857 
dermoid of bladder, 643 

of Fallopian tube, 853 

of ovary, 680, 859, 873, 875, 881 
gaseous, vulvar, 623 
glandular, 864, 868 
hydatid of Morgagni, 191, 853 
intraligamentary, 867 
Nabofhian, 377, 512, 746, 778 
of vagina, 637 
parovarian, 857 
residual, 861 
retention, 377, 637 



Dartoid, 159 

Death after hysterectomy, 740 

after removal of large tumors, 922 
causes of, after hysterectomy, 740 

Deciduo-chorion cellulare, 832 



INDEX, 



937 



Dendritic growths, 872 
Dermoid cyst, 873, 879, 884, 894 

diagnosis, 900 

of bladder, 643 

of Fallopian tube, 853 

of ovary, 859, 873, 883 
peritonitis from, 884 

rupture of, 884 
Descent or prolapsus of the ovary, 231 
Desmoid tumor of abdominal walls, 

98, 676, 888 
Desmopy Gnosis, 535 
Destructive bladder mole, 832 

placental polyp, 743, 832 
Dextroflexion, 546 
Diabetes mellitus, cause of vulvitis, 

.334. 3.38 
Diagnosis, 14 

cause of error in, 14 
importance of correct, 13 
method of procedure in, 14 
senses employed in, 22 
Diaphragm, pelvic, 170. See Perineal 

muscles. 
Diarrhea, 17, 885, 899 
Diet after operation, 133 
in pelvic cellulitis, 439 
in ureteritis, 373 
Digitalin, 391 
Digitalis, tincture of, 391 
Dilatation of the urethra, 91 
of the uterus, 571, 705 
bloodless, 43 
bougies, 571 
divulsion, 45 
gauze packing, 48, 571 
gradual, 46 
incision, 46 

bilateral, 47 
rupture of uterus by, 46 
tents, 44, 512 
Dilators, Hegar's, 705 

Pratt's, 46, 408 
Diplococcus intracellularis meningiti- 
dis, 90 
of Siegelman, 73 
Discharge, genital, 21 
catarrhal, 21 
cervical, 22 
effect of age upon, 22 
origin of, 2 1 
simulating abscess, 21 
sources of purulent, 21 
vaginal, 22 
Discus proligerus, 189 
Disease, origin of, i 
Dislocations of uterus, 500 
anteposition, 500 
dangers of sound in, 500, 
diagnosis, 500 
lateral position, 500 
retro-position, 500 
torsion, 472, 501 



Displacements of the appendages, 564, 
680 
diagnosis, 565 
symptoms, 565 
treatment, 566 
of the ovary, 231 
of the pelvic organs, 466 
of the uterus, 470, 679 
classification of, 471 
anteflexion, 472, 506 
antelocation, 471 
anteversion, 472, 501 
ascent, 472 

descent, or prolapsus, 473 
dextroflexion, 472 
dextrolocation, 471 
dextroversion, 472 
retroflexion, 472 
retrqlocation, 471 
retroversion, 472 
sinistrofiexion, 472 
sinistrolocation, 471 
sinistroversion, 472 
torsion, 472 
complications, 546 
conditions which cause, 470 
diagnosis of, 473 
digital examination in, 482 
prognosis, 547 
treatment, 547 
electricity, 547 
general, 547 
massage, 547 
mechanical measures, 547 
summary in, 548 
Diuresis, 885 
Diuretics in cancer of uterus, 828 

in gonorrheal and acute cystitis, 374 
Divulsion, uterine, 45 
Douche. 143, 510, 548, 572 
alkaline, 353 
antiseptic, 382 
astringent, 143, 354 
bichlorid, 716 
hot, 258, 381, 400, 406, 426, 439, 

488, 502, 572 
intrauterine, 390 
rectal, 143 
th3'mol, 143 
urethral, 359 
vaginal, 258, 290, 359, 381, 400, 426, 

439- 548, 572 
vesical, 144 
Douglas, pouch of, 199 
Drain, gauze, 128, 451, 648 
where placed, 128 
Mikulicz, 127 
Drainage, 125, 410, 715, 913, 914 
management of, 126 
objections to, 126 
postural, 128, 455 
tube, 126, 715 
Dressing of wound, 131, 907, 914 



938 



INDEX. 



Dressings, io8 
Dropsy, hepatic, 893 

cardiac, 890 

renal, 890 
Dudley's operation for prolapsus uteri, 

499 
denudation, 314 
Duke's operation, 322 
Duverney's gland, 339 
Dysmenorrhea, 18, 149, 152, 154, 214, 
219, 396, 403, 508, 510. 549, 670 
from obstruction of uterine canal, 

509 
Dyspareunia, 19, 345, 627 
Dyspnea from cysts, puncture for, 905 

E. 

Echinococcus cysts, 857, 901 

Ecraseur, wire, 563, 784 

Ectopia of bladder, 248 

Eczema of vulva, 332, 334, 336, 341 

from carcinoma, 827 
Edema, malignant, 660 

of labium, 575, 628 

of leg a symptom of cancer, 901 

of vulva, 338 

preliminary puncture of cysts for, 

905 
Electricity, 142, 384, 547, 610 

Apostoii's method, 151, 701 

apparatus for application, 150 

battery for, 150 

contraindications, 152 

electrodes, 150 

faradic, 149, 152, 411 

Finsen light, 155 

forms of, 149 

franklinic, 149 

galvanic, 149 

in fibroid growths, 700 

in lateral flexion, 547 

indications, 152 

methods of procedure, 151 

Rontgenic, 149 

sinusoidal, 149, 153 
Electrocautery and light, 155 
Electrode, bladder, 151, 701 

clay pad, 151, 701 

insulated probe, 151, 701 

metal, 150, 151 

water, 701 

wet towel, 151, 701 
Electrolysis in ovarian growths, 902 
Elephantiasis of vulva, 628 
Elytritis, 348 
Elytrotomy, 610 
Embolism, 138, 741 
Embryology and anatomy of the gen- 

ito-urinary organs of the woman, 

156 
Emmet's operation for complete lac- 
eration, 312 



387. 397 
associated 



with, 380, 



Emmet's operation for lacerated cer- 
vix in metritis, 408 
on the perineum in relaxation of 
posterior vaginal wall, 309 
Enchondroma, 633, 853 
Endocervicitis, 375 
symptoms of, 375 
Endometritis, 375, 384, 394, 679, 743 
acute. 384 
chronic, 394 
diagnosis of, 
discharge 

395 

vegetations of the mucous mem- 
brane, 394 

villous degeneration, 395 
exfoliative, 396 
fungosa, 396 
gonorrheal, 384, 396 
hemorrhagic, 19, 404 
influence of, upon conception, 397 
membranous, 396 
pathologic alterations, 385, 400 
prognosis, 389 

results of neglected cases, 398 
senile, 396 

symptoms of, 386, 396 
treatment, 389, 398 

caustics in, 399 

cureting, 398, 399, 400 
contraindications for, 399 

dilatation with laminaria tents, 

399 
drainage in, 399 
hot vaginal douche, 400 
intrauterine injections, 399 
intravenous injections, 391 
irrigation with antiseptics, 398 
prophylactic, 398 
repair lacerations, 398 
scarification, 400 
tampons, 399 
varieties and source, 385 
virginal, 396 
Endometrium, tuberculosis of, 849 
Endoscope, Skene's urethral, 92 
Endothelioma of ovary, 878 

uteri, 835 
Enema, alum, 134 
nutrient, 133 
quinin, whisky, and water, 134, 

451 
soapsuds, turpentme, and eggs, 134 
Enemata, 451, 548, 828 
alum, 451 
coffee, 135 
glycerin, 450 

in intestinal distention, 451 
medicated, 144 
normal salt solution, 134 
peptonized milk, 134 
rectal, 134, 426, 548 
soap and water, 450 



INDEX. 



939 



Enemata, stimulants, 134 

whisky, 134 
Enterocele, vaginal, 340, 48 5 
Enteroptosis, how avoided, 550 
Eosin. 55 

Epilepsy, 215, 403 
Epiplocele, 340, 858 
Episiostenosis, 278 
Epispadias, 246 

treatment of, 248 
Epithelial pearls, 634, 748 
Epithelioma of uterus, 748 
of vagina, 640 
of vulva, 633 
Erector clitoridis muscle, 165 
Ergone, 135, 918 
Ergot, 100, 141, 406, 572, 698 
Ergotin, 569, 609 
Eruptions, vulvar, 27 
Erysipelas of the vulva, 334 
Erythrocytes, 83 

increase in number of, 85 
pathologic alteration of, 85 
Ether, sulphuric, 407 
Ethyl bromid, 115 

clilorid, 115 
Etiology, 2 

hereditary and congenital, 3 
hygienic, 5 
incident to age, 11 
infective, 10 
sexual, 7 
traumatic, 8 
Eucalyptus, 346 
extract of, 637 
Examination, 23 

abdominal preliminaries, 23, 96 
aspiration, 10 1 
auscultation, 99 
exploratory incision, 102, 902 

puncture, 100, 901 
inspection, 27, 888 
palpation, 98 

difficulties in, 99 
percussion, 99 
preliminaries, 96 
tapping, 100 
instrumental, 34 
precautions, 37 
probes, 35 
Sims', 35 
whalebone, 35 
sound, 34 
speculum, 37 
tenaculum, 41 

double, 43 
tubular, 37 

univalve or duck bill, 41 
valvular, 38 
microscope, 48 

collection of tissue, 49 
disposition of tissue, 52 
test curetment, qo 



Examination, microscope, test excision, 

49 
pelvic, 23, 27 

bimanual procedure, 30, 672 
difficulties of, 30 
digital, 27, 30, 776 
precautions in, 34 
in virgins, 30 
inspection, 27 
position of the patient, 23 
preliminaries, 23, 27 
preparation, 27 
procedure, 27 
rectal touch, 31, 819 

conjoined manipulation in, 32 
recto-abdominal, 31, 32 
rectovaginal, 32 
recto-vagino-abdominal, 31, 32 
recto-vesical, 31, 32 
Simon's method, ^3 
simple touch, 27 
Exercise, rest and, 142 
Exophthalmic goiter, 699 
Exploration of urethra, bladder,, and 

ureters, 91 
Exstrophy of bladder, 241, 246 
Extract, adrenalin, 700 
belladonna, 369 
cannabis indica, 698, 699 
condurango, and vaselin, 829 
gelsemium, 426 
hamamelis, 699 
hydrastis canadensis, 407, 699 
opium, 369 

thyroid gland, 141, 142, 510, 572, 699 
ustilago maidis, 698 
Exudates, pelvic, 154, 434 



Facies ovariana, 13, 879 

uterina, 16 
Failure in microscopic examination, 60 
Fallopian tubes, 184, 852 

absent or rudimentary, 230 
accessory ostia, 231 
adherent, 447 
I anomalies in length, 231 

coats of, 184 
mucosa, 185 
muscular, 185 
serous, 184 
i subserous, 184 

j description of, 184 

j divisions of, 184 

; ampulla tubse, 184 

fimbriated extremity, 184 
. infundibular tubae, 184 

I isthmus tubas, 184 

; ostium abdominale tubse, 184 

ostium uterini tuhse, 184 
pars uterini, 184 
epithelium of, 186 



940 



INDEX. 



Fallopian tubes, inflammation of, 411. 
See Salpingitis. 
length of, 184 
openings of, 184 
tumors of, benign, 852 

cysts of small size, 853 
dermoid, 853 
enchondromata, 853 
librocyst, 853 
fibroma or myoma, 852 
papillomata, 854 
hydropic, 854 
simple cystic, 854 
polypus, 854 
malignant, 855 
carcinoma, 855 
chorioepithelioma, malignum, 

856 
sarcoma, 855 
treatment of, 855 
Faradic current, 152, 411 
Farre, white line of, 187 
Fascia, anal, 169 
deep, 168 

layer of superficial, 168 
obturator, 169 
pelvic, 169 
perineal, 168 
pyriform, 169 

relation to pelvic structures, 169 
superficial, 168, 169 
triangular ligament, 168 
vesico-rectal, 169 
Fecal fistula, 264 

incontinence, 292 
Fecundation, 212, 223 

union of spermatozoid and ovum, 
223 
Feeding, rectal, 134 

liq. sesquichlor., 58 
Ferri persulph., 569 
Fetal heart sounds, 99 
Fever, puerperal, 387 
Fibrocyst, 853 

Fibroid growths in the fundus a cause 
of anteversion, 502 
polypus, 660 
tumors and polypi, 638 
Fibroids, recurrent, 844 

sloughing, 114 
Fibroma of broad ligament, 858 
and myxoma, 633 
submucous, 654 
of tubes, 852 
Fibromyoma of cervix, 662 
of ovary, 876 
of uterus, 650 
Fibromyomata, 650 
Fibrosarcoma, 840 
Filaria, embryo of, 90 
Filter paper, 57 
Fimbria ovarica, 187 
Finsen light, 155 



Fissure, anal, 17, 506, 518, 667 
vesico-urethral, 357 
appearance of, 358 
site of, 357 
Fistula, 17 
Fistulas, 264, 823 
causes of, 264 
cervical, 282 
cervico-vaginal, 291 
classification of, 264 

fecal, 264, 289, 919, 921 
ano-vulvar, 264, 290 

treatment, preliminary and 
after, 290 
entero-vaginal, 264, 291 
recto-vaginal, 264, 266, 289 
genito-urinary, 264 
uretero-vaginal, 264 
urethro-vaginal, 264, 279 
urinary, 920 
utero-ureterine, 264 
vesico-uterine, 264, 267 
vesico-utero-vaginal, 282 
vesico-vaginal, 264, 268, 640 
intestinal, 751 
diagnosis of, 265 
etiology of, 264 
prognosis of, 267 
symptoms of, 265 
treatment, 267 , 

accidents and results of, 287, 288 
calculi and concretions, 288 
hemorrhage, primarv, after, 
287 
secondary, after-, 287 
inclusion of ureters, 288 
peritonitis, 288 
after-, 277 

by cauterization, 268 
by colpocleisis, 278 

combined with recto-vaginal fis- 
tula, 279 
objections to, 279 
by denudation and suture, 267 
by episiostenosis, 278 
by flap-formation, 267, 289 

advantages of, 276 
by flap-splitting, 267, 289 
by hysterocleisis, 281 
by hysterostenosis, 281 
preliminary, 268 
uretero-vaginal-uretero-cervical, 283 
treatment of, 283 

by anastomosis through the ab- 
domen, 283, 285 
through the vagina, 283, 284 
by introduction of the ureter 

into rectum or colon, 284 
by ligation of the ureter, 284 
by nephrectomy, 284 
urethro-vaginal, 279 
vesico-uterine, 280 
vesico-uterovaginal, 282 



INDEX. 



941 



Fistula, vesico-vaginal, treatment, 268 
Corson's method of flap-splitting, 

271 
denudation for, 267 
flap-formation, 267, 289 
flap-splitting, 267, 270 
flap-transplantation, 274, 290 
Flap operations, 270, 289 
Flatus, rectal irrigation for, 851 
Flexion, anterior, of uterus, 506 
lateral, 546 
posterior, 514 
prognosis, 547 
treatment. 547 
electricity, 547 
massage,' 547 

mechanical measures, 547, 548 
operative procedures, 549 
Fluids and secretions, collection of, 75 
Follicular cysts, 862 
Fomentations, antiseptic, 336 
hot, 439, 450 

of lead water and laudanum, 343 
Forceps, 820 
dissecting, 125 
Koeberle, 795 
needle, 129 
O'Hara, 919 
pedicle, 613 
pressure, 124 
shovel, 795 
tube, 126 
Formalin, 53, 59, 382 
Fornix, anterior vaginal, 173 

posterior vaginal, 173 
Fossa navicularis, 165 
Fourchet, 160, 165 
Fowler's solution, 133 
Franklinism, 149 

Freund's denudation in laceration of 
perineum, 308 
operation for malignant disease, 800 
for shortening the utero-sacral 

ligaments, 546 
in marked prolapse, 497 
Friedrichshall water, 141 
Fritsch's operation, 321 
Fuchsin. 57 
Furuncle, 332, 340 

G. 

Gall-stone colic, 899 
Galvanic current, 149, 343, 347 
contraindications for, 152 
indications for, 152 
Galvanism, 149 

apparatus for, 150 

contraindications, 152 

in chronic endometritis, 150 

in fibroid tumors, 150 

indications, 152 

peh^ic inflammatory exudates, 150 



Galvano-cauter}^ 636 

knife, 785 

loop, 644, 784 
Galvanometer, 150, 151 
Gangrene of fibromyomata of uterus, 
696 

of vulva, 338 
Gartner, canal of, 191 
Gauze, 105, 113 

acetanilid, 113 

borated, 113, 258 

carbolized, 113, 258 

drain, 128, 451, 808, 811, 914 

for dressings, 108 

for pledgets, 820, 823 

formalized, 113 

iodoform, 258, 825, 919 

pack, 48, 113, 125, 409, 465, 503, 
573, 576, 615, 714, 716, 791, 821, 
831, 913, 919 

pads, 105, 323, 336, 410, 453, 727, 

no 

salicylated, 113 
sterilized, 105, 258 
sublimate, 113 
tampons, 146, 823, 914 
thymolized, 258 
wick, 126, 136, 456, 574, 914 
Genital canal, atresia of, 237 

treatment of acquired, 238 
of -congenital, 238 
laceration of, 291 
hemorrhage or bleeding, 574 
organs, 159 

development of, 156 
functions of, 212 

copulation, 159, 223 
fecundation, 212, 223 
injuries of, 250 

treatment, 251 
menstruation, 213 
nubility, 212, 213 
parturition, 212 
puberty, 212 
malformations of, 223 "^ 
classification, 223 
acquired, 27, 224 
congenital, 27, 224 
tract, bacteriology of, 60 

parasites of, 61 
tumors, 621 
benign, 621 
definition of, 622 
difficulty of differential diagnosis 

in, 622 
malignant, 621 
Genitalia, division of, 159 
external, 159 
internal, 172 
lymphatics of, 208 
Genito-urinary fistulse, 264 
organs, bifidities of, 224 
degrees of division of, 224 



942 



INDEX. 



Genito-urinary organs, development of, 
156 
physiology of, 212 
tract, inflammation of the entire, 
326 
Gentian, compound tincture, 407 
Germinal epithelium, 188 
spot, 189 
vesicle, 189 
Germs, pyogenic in discharge of uter- 
ine cancer, 805 
Gestation, 212 

ectopic, 569, 896, 899 
adipocere in, 596 
causes of, 582 
course and progress of, 585 
abortion, tubal, 588 
mesometric or intraligament- 

ary, 591 
moles, tubal, 588 
rupture, complete, 592 
incomplete, 592 
primary, 589 
secondary, 589, 594 
lithopedion, 595 
termination of, 595 
diagnosis, 599 
differential, 604 

from acute intestinal ob- 
struction, 607 
from fecal accumulation, 605 
from intraligamentary tu- 
mors, 605 
from ovarian tumors. 605 
from perforating ulcers in 
duodenum, 607 
in small intestine, 607 
in the stomach, 607 
in vermiform appendix, 
607 
from pregnancy, extrauterine 
with dead fetus, 606 
in one horn of bicornate 

uterus, 605 
spurious, 605 
uterine, 605 
from pregnant uterus, retro- 
flexed, 605 
from renal and biliary colic, 

607 
from rupture of pyosalpinx, 

607 
from strangulated hernia, 607 
from torsion of pedicle of 

small ovarian cyst, 607 
of tubal rupture, 607 
uterine tumors, 605 
lithopedion in, 595, 596 
macerated fetus, 604 

treatment of, 620 
mummification of fetus, 596 
pathological features of, 607 
prognosis, 608 



Gestation, ectopic, symptoms, 596 

discharge of decidual mem- 
branes, 598 
hematocele, anteuterine, 567 

circumuterine, 567 
hemorrhage, extraperitoneal, 
576 
intraperitoneal, 576 
secondary rupture, 589, 594 
treatment, 609 

electricity, 155, 609 
elytrotomy, 609, 610 
evacuation of liquor amnii, 609 
four stages of operation, 611 
in rupture into broad ligament, 

injection of poison into fetus, 

609 
operative, 611 

incision, abdominal, 611 

extirpation of entire sac, 

619 
removal of placenta 

without sac, 617 
Sutton's rules, 618 
three terminations, 617 
vaginal, 610 
varieties of, 584 
abdominal, 585 
tubal, 584 
tubo-ovarian, 585 
interstitial, 585 
Getting up, after operation, 140 
Gland, Bartholin's, 167, 339 
Cowper's, 339 
Duverney's, 339 
obturator, of Guerin, 209 
Glands, hypogastric or iliac, 208 
inguinal, 208 
lumbar, 209 
lymphatic, 208 
sacral, 209 
utricular, 217 
Glandulae vestibulares minores, 192 
Glandular cyst, 864 
Glass plug, 235 
Gloinin, 906 
Gloves, rubber, 109 
Glycerin, 114, 147, 408 

on tampons, 548 
Glycerin-gelatin, 54 
Glycerite of tannin, 147 
Gonococcus of Neisser, 63, 65, 90, 333, 

352, 353 
examination for, 66 
ichthyol destructive to, 354 
Gonorrhea, 358, 359, 854 

a cause of inflammation, 328, 329, 

330, 332, 372, 411, 441 
more dangerous than syphilis, 329 
too frequently regarded unimpor- 
tant, 449 
Graafian follicles, 189 



INDEX. 



943 



Graafian follicles, corpus luteum of, 190 

nucleus of, 189 
Growths, fibroid, 502, 516, 547, 657 

ovarian, 502, 547, 859 

retrouterine, cause for uterine ascent, 

^ 473 . 
Gynandria, 244 
Gynecology, definition, i 

difficulties in study of, 12 

theories of, i 

value of notes in, 13 
Gyroma, 877 



H. 

Hamamelis, 141, 143, 407, 569, 572, 

698, 699 
Hands, preparation of, 108, 120 
Hearing, how utilized, 22 
Heart failure, 102 
sounds, fetal, 99 
Heat, artificial, 132, 135 
Hegar's operation, 301 

modified, 303 
Hematometra, 742 
Hematosalpinx, 414, 446, 895 
Hemoconia, 83, 85 
Hemocytometer, 80 
Hemoglobin, St, 
estimation of, 81 
relation of, to surgery, 84 
scale, 82 
Hemoglobinometer, 81 
Hemorrhage, 18, 147, 330, 566, 643, 
733. 737. 740, 741, 784, 802, 852, 
882, 885, 918 
a symptom, 566 
after removal of clamps, 852 
causes of, 19 
from urinary tract, 93 
genital, 569 
causes, 569 
diagnosis, 570 
dilatation, 571 
with bougies, 571 
with dilators, 571 
with tents, 571 
importance of careful examina- 
tion in, 570 
genito-urinary, 566 
hematocele, 567 
diagnosis, 567 

differential, from pelvic abscess, 

579 
from rupture of pyosalpinx, 

579 
from retrofiexed gravid ute- 
rus, 579 
extraperitoneal, 567, 576. 578 
intraperitoneal, 567, 576 
diagnosis, 579 
symptoms, 578 
a cause of uterine ascent, 473 



Hemorrhage, hematocele, intraperi- 
toneal, a source of peritoneal in- 
flammation, 449 
prognosis, 580 
treatment, 580 
cision, abd 
vaginal, 581 
ligation of bleeding vessel, 
580 
hematocolpometra, 240 
hematocolpometrosalpinx, 238, 567 
hematocolpos, 238, 567 
hematoma, 441, 567, 637 
ovarian, 191 

vaginal or thrombus, 573 
diagnosis, 575 
from pressure during labor upon 

an ovarian dermoid, 575 
treatment, 575 
vulvar, 573 

diagnosis of, 575 

differential, from edema of 
labium, 575 
from labial tumors, 575 
during ovariotomy, 912 
treatment of, 575 
hematometra, 239, 567, 742, 824, 
842, 898 
unilateral, 366 
hematosalpinx, 238, 567, 824, 895 
hematoxjdin. 55, 56 

staining, 56 
hematuria, 567 
causes, 567 
in cystitis, 567 

tubercular, 365, 367 
in disease of ureter and pelvis of 

kidney, 567 
malarial, 567 
site and varieties, 566 
symptoms and diagnosis, 567 
treatment, 568 
astringents, 569 
operation, 569 
internal, 135, 330, 918 '^ 

menorrhagia, 567 
metrorrhagia, 567 
ovarian apoplexy, 567 

hematoma, 567 
periuterine, 576 
causes of, 576 
symptoms of, 577 
primarv, after fistula operation, 

2S7 ' . ,- 

secondarv, after fistula operation, 

287 
treatment, 572 
urinary, 567 

diagnosis, 567 

symptoms, 567 
uterine, thyroid extract in, 141 
vesical, 93 
vulvo-vaginal thrombus, 567 



944 



INDEX. 



Hemorrhoids, 17, 32, 140, 341, 342, 
506, 667, 670, 671 

from pressure upon rectum, 506 
Hemostasis, electrothermic, 156, 797 

in ovariotomy, 800 
Heppner's method of suturing, 307 
Heredity, 666, 766 
Hermaphroditism, 243 

androgyna, 245 

epispadias, 246 
treatment of, 248 

gynandria, 244 

hypospadias, 246 

pseudo-hermaphroditism, 243 
divisions of, 243 

true, 243 
Hernia, 168 

fatty, 858 

labial, anterior, 623 
posterior, 623 

ovarian, 623 

vaginal, 485 

ventral, 98, 723, 888 
Herpes of the vulva, 332, 334 
causes of, 334 
diagnosis of, 335 
Hildebrandt's denudation, 306 
History, method of securing, 13 
Hot fomentations, 439, 450 
Hottentot apron, 161, 241 
Hot-water bag, 369 

bottles, 132, 426 
Houston, valve of, 196 
Hunyadi Janos water, 141 
Hydatid cysts of the uterus, 742 
of Morgagni, 191, 853 

disease, 10 1 
Hydramnios, 896 
Hydrarg. chlor, mit., 133 
Hydrastin, 141, 572, 699 
Hydrastinin, 141, 572, 698 
Hydrastis, 141, 143, 569, 572 

canadensis, 141, 360, 407, 699 
Hydrocele, 168, 340, 624 
Hydrogen dioxid, 113, 383 

peroxid, 822 
Hydrometra, 410, 742, 898 
Hydronephrosis, 672, 751, 769, 901 
Hydrops folliculorum, 862 

tubce profluens, 21, 415, 864 
Hydrorrhea, 403, 410 
Hydrosalpinx, 415, 419, 446, 895 
Hydrotherapy, 143, 406 
Hymen, 164 

annular, 164, 243 

anomalies of, 27 

atresia of, 243 

biseptus or septus, 164, 243 

carunculas myrtiformes, 165, 243 

congenital absence of, 243 

crescentic, 164 

cribriform, 165, 243 

cysts of, 629 



Hymen, defects of, 242 
falciform, 164 
imperf oration of, 243 
incision of, 243 
infundibular, 164, 243 
labia-like, 164 
laceration of, 243 
linguaformis, 164 
rupture of, 165 
shape of, 243 
supernumerary, 243 
Hyperemia of the urethra, 354 

treatment, 359 
Hyperplasia, 379 

Hypodermocleisis of normal salt solu- 
tion for hemorrhage, 135, 918 
for peritonitis, 136 
Hypospadias, 5, 246 
Hysterectomy, abdominal, 799 
accidents during, 737 
hemorrhage, 737 
injuries of viscera, 737 
injury of intestine, 739 
of ureter, 738 
after-treatment, 740 
causes of death after, 740 
pan-, 729 
partial, 723 
vaginal, 716, 790 

by morcellement, 712 
description of operation, 716 
mortality of, 814 
Hysteria, 152, 403 

Hysterostenosis, or hysterocleisis, 281 
Hysterotome, 742 
Hysterotrachelorrhaphy, 259 



Ice suppositories, 135, 581 

Ice-bag, 137, 263, 337, 369, 425, 427, 

439. 45O' 489 
] in dysmenorrhea, 144 
i Ice-water irrigation, 820 

Ichthyol, 147, 258, 383, 426 
I Ileus, 741, 883, 899, 922 
Immunity, natural agents of, 62 
Incision, abdominal, 121, 907 

abdominal, for tumors of the bladder, 
i 645 

: crescent, 123 

exploratory, 102, 902 
j length of, 121 

ovoid, 792 
j vaginal, for tumors of the bladder, 

i 645 

i Infection, 102, 327, 355, 356, 357, 362, 
378, 384, 385. 386, 388, 392, 411, 
417, 420, 421, 441, 442, 462, 665, 
744, 751. 775. 787, 796, 805, 857, 
884, 902 
gonorrheal, 358, 363, 379, 411 
how favored, 384 



INDEX. 



945 



Infection, localized points of, 392 
ovarian, 442 

specitic, 350, 356, 357, 411 
streptococcic, 349 
wound, 136 
Inflammation, 326 

acute, 327 * 

causes of, 328 

etiology of, 327, 328, 361 
gonorrhea and traumatism 

most prolific, 328 
micro-organisms as a cause, 327 
symptoms of, 330 
discharge, 351 

disturbances of menstruation, 
328 
and suppuration of C3^st, 883 
appendiceal, 98 
characteristics of, 329 
chronic, 149, 327 
classification of, 330 
exacerbations in, 329 
follicular, of urethra, 356 
immunity against, how lost, 327 
natural protection against, 327 
of bladder, 361 
acute, 362 

symptoms of, 362 
chronic, 363 

symptoms of, 363 
of cervix and body of uterus, 374 
of entire genito-urinary tract, 326 
of Fallopian tube, 411 
diagnosis, 419 
prognosis, 420 
symptoms, 418 
treatment, see Sec. 459 
of ovary, 421 
diagnosis, 425 
symptoms, 424 
treatment, 425 
of peritoneum, acute, 439 
adhesive, 444 
chronic, 445 
serous, 444 
suppurative, 444 
of ureter, 372 
of urethra, 354 

treatment, 359 
of vagina. See Vaginitis. 
of vulva. See Vulvitis. 
pelvic, 430 

erroneous views of, 430 
peritonitis, parametritis, perisal- 
pingitis, and perioophoritis. 
See Pelvic peritonitis. 
varieties of, 327, 430 
acute, 327 
chronic, 150, 431 
circumscribed, 327 
diffused, 327 
periuterine, 154 
Injections, bovinin, 134 
60 



Injections, carbolic acid, 113 
carbolized water, 359 
chlorid of sodium and sublimate, 825 
colored fluid in fistulse, 266 
deodorizing, 113 
dioxid of hydrogen, 113 
disinfectant, 113 
formalin, 113 
I guaiacol in olive oil, 371 
j hot vaginal, 343 

hydrogen peroxid and thymol, 827 
hypodermic, absolute alcohol, 825 
adrenalin chlorid, 135, 391 
; atropin, 135, 391, 451 

digitalin, 391, 451 
ergone, 136 

morphin, 134, 137, 451, 609 
pyoktanin, 825 
salicylic acid and alcohol, 825 
strvchnin, 135, 136, 391, 451, 906, 
918 
intra-intestinal, 451 
intrauterine, 113, 400 
intravenous, of corrosive sublimate, 

391 
of normal salt solution, 391, 451 
of quinin, hA^drochlorid of, 391 
lime-water, 342 
milk, 266 
paraffin, 341 
parench^^matous, 825 
perchlorid of iron, 572, 700 
permanganate of potash, 827 
persulphate of iron, 573 
quassia, 342 

quinin, whisky and water, in intes- 
tinal distention, 451 
silver nitrate, 359, 825 
sublimate, 113, 359 
tincture of iodin, 700 
vinegar water, 700 
zinc chlorid, 359 
Inspection, 27, 97 
Instruments for ovariotomy, .905 

for trachelorrhaphy, 259 
Insufflator, 146 
Internal genitalia, 172 

hemorrhage, 135, 330, 918 
Interstitial, mural, or centric fibroid 
growths of the uterus, 657 
\ Interureteric ligament, 194 

Intestinal catarrh, 152 
I complications, 921 
perforations, 441 
Intestine, injurj^ to, during operation, 
.739. 918 
kinking of, 740 
Intraligamentary cysts, 867, 879, 880 
Intrauterine douches, 390 
Intussusception, 137 
I Inunctions of mercury, 609 
i Inversion of the uterus, and complica- 
' tions, 551 



946 



INDEX. 



Inversion, degrees, 551 
extra-vaginal, 550 
intrauterine, 550 
intra vaginal, 550 
invagination, 551 
diagnosis of, 555 

differential, from fibroid tumors, 

557 
etiology, 553 

nonpuerperal, 553 
puerperal, 553 
symptoms, 554 
treatment, 557 
instrumental, 559 
operative, 559 

incision of vagina and posterior 

uterine wall, 562 
taxis, 559 
central, 559 
lateral, 559 
peripheral, 559 
Thomas operation, 560 
lodin and carbolic acid, 409 
and perchlorid of iron, 409 
compound tincture of, 337 
tincture, 114, 133, 144, 145, 146, 382, 
3^3^ 399. 409, 426, 503, 648, 700, 
705. 707. 776, 822 
Iodoform, 145, 146, 409, 637, 705 
and charcoal, 637 
gauze tampons, 113, 146, 826 
pencils, 146 

poisonous effects of, 113 
lodol, 113 
lodophilia, 80 
Iron, 141, 381, 409 

perchlorid of, 409, 572 
persulphate, 5^9;. 573- 632, 723 
tincture of chlorid of, 146 
Irrigating tubes, 112 
Irrigation, 125, 371, 393, 700, 790, 793, 

91.3 ^ 
continued, no 

in suppurative peritonitis, 451, 455 
of stomach, 134 
vaginal, 112, 140 
with antiseptics, 827 
Ischioperineal ligament, 168 

J. 

Judgment, exercise of, 13 

K. 

Keratinization, 748 
Kidneys, amyloid degeneration of, 770 
disease of, 341, 374 
floating, 681 
removal of, 739, 920 
sacculation of, 770 

associated with uterine cancer, 
770 



Kobelt's tubules, 875 
Koch's bacillus, 364 
Kraurosis vulvae', 343 
causes of, 344 
diagnosis of, 345 
division of, 343 
pathology of, 343 
prognosis of, 345 
symptoms, 344 
treatment, 345 
Kreatinin in cysts, 901 



L. 



Labia majora, 159 

agglutination of, 237 
anatomy, 159, 168 
tumors of, 27 
minora, 160 

anatomy of, 160 
elongation and thickening~of, 27 
Lacerations of cervix, 254 
complications of, 257 
diagnosis, 255 
symptoms, 255 
treatment, 257 
after-, 263 

amputation of cervix, 261 
preliminary, 257 
trachelorrhaphy, 259 
of pelvic floor, 291 
causes, 292 
degree or extent, 293 
operation for complete, 295, 303 
for incomplete, 295, 300 
after-treatment, 323 
choice of operation in, 325 
intermediate operation, 298 
primar}^ operation, 296 
advantages of, 297 
contraindications, 298 
secondary operation, 299 
results, 294 
of sphincter ani, 292, 294, 297, 303 
of vagina, 263 
Lactation' prolonged to avoid con- 
ception, 217 
Lanolin, 360 
Lauenstein's method of suturing, 306, 

322 
Laxatives, 140, 353, 851 
Lead acetate, 143 

Lead-water and laudanum ,337,489,822 
Leucin in cysts, 901 
Leukocytes, 83, 87 
Leukocytometer, 81 
Leukocytosis, 87 
experimental, 89 
inflammatory, 88 
malignant, 89 
of digestion, 87 

of pregnancy and parturition, 87 
pathologic, 88 



INDEX, 



947 



Leukocytosis, phagocytosis, 88 
posthemorrhagic, 88 
terminal, 87 
thermal and mechanical agencies in, 

87 
Leukolysis, 86 
Leukopenia, 86 

Leukorrhea, 13, 20, 21, 255, 259, 379, 
403, 404, 424, 505, 719 

in cervical inflammation, 379 

sources of, 20 

substitute for menses, 505 

symptom of metritis, 403 

with submucous growths, 669 
Levator ani muscle, 165, 169, 292, 297, 

.305 
Lieberkuhn's crypts, 195 

follicles, 197 
Ligament, broad, 231, 467 

infundibulo-pelvic, 184, 197, 565, 

566, 729 
interureteric, 194 
ischioperineal, 168, 169 
of rectum, 169 
of uterus, 211 
ovarian, 186 
Poupart's, 168 
pubo-vesical, 191 
round or broad, defects of, 231 
triangular, 168, 191 
uterosacral, 211, 467, 496, 526, 544 
uterovesical, 211, 467 
Ligature and suture material, 106 
catgut, 107, 724 
partition, 724 
rubber, 724 
silk, 106, 716, 724, 912 
wire, 912 
Linea alba, 121 
ani rectalis, 195 
nigra, 97 
striata; 97 
Lint, surgeon's, 337 
Liomyomata, 654 
Lipoma, 633 
Lipomata, 858 
Liquor aluminii acetici, 648 
ferri chloridi, 792 
ferri sesquichloridi, 824 
sanguinis, 82 
Lithopedion, 596, 619, 620 
Lupus, 69 

Lymphangiectasis, 853 
Lymphatic system, 208 
glands, 208 

hypogastric, 208 
inguinal, 208 
lumbar, 209 
of Guerin, 209 
pelvic, 208 
sacral, 209 
vessels, 209 
Lymphosarcoma, 840 



M. 
Macroblasts, 83 
Macrocytes, 83 
Magnesia mixture, 134 

sulphate, 133, 407, 439, 451 
Magnesium citrate, iii 

phosphate, 83 
Malarial plasmodia, 90 
Malformations, classification and defi- 
nition of, 223 
congenital and acquired, 27 
treatment of, 233 
Malignancy, proportion of, in ovarian 

tumors, 903 
Malignant chorion, 832 
disease, 10 1 

of colon, 98 
neoplasms, 639, 743 
Malt extracts, 407 
Mammary gland extract, 572, 700 
Marasmus, 899, 901 
Martin's method of suturing in lacera- 
tion of perineum, 316 
Massage, 142, 147, 411, 429 
general, 147, 374 
pelvic, 147, 503, 524 
contraindications, 149 
difficulties of, 149 
in anteversion, 504 
in lateral flexion, 547 
indications for, 149 
Masturbation, 242, 328, 335, 341 
Meatus urethrae externus, 163, 192 

construction of, 192 
Membrana granulosa, 189 
Menopause, 221 

chemic changes in blood and tissues, 

222 
duration, 221 
early, 221 

hemorrhages during, 222 
premature, 221 
retarded or delayed, 221 
time of occurrence, 221 -^ 
vasomotor disturbances of, 222 
treatment, 222 
Menorrhagia, 18, 152, 214, 220, 403, 

408, 424, 438, 505, 567, 668 . 
Menses, 13 
Menstruation, 213 

after complete removal of ovarian 

stroma, 216 
amount of blood lost, 214 
and ovulation, 213 
disturbance of, 18, 216 

of mental equilibrium in, 215 
duration of, 214 
during pregnancy, 217 
influence of cessation of, upon the 
cervix, 180 
of nerves in, 217 
of ovarian tumors upon, 880 
intervals of, 214 



948 



INDEX. 



Menstruation, purpose of, 215 
retained, from atresia, 237 
symptoms of, 215 
synonyms of, 213 
time of occurrence of, 214 
vicarious, 217 
Menthol, 343 
Mercuric oleate, 360 
Mercury, 141, 609 
Mesenteric artery, ligation of, 917 
Mesovarium, 187 
Metalbumin in cyst contents, 871 
Metastasis chorioepithelioma, 834 
of carcinoma, 788, 818, 855, 901 
papillary variety ovarian tumors, 
917 
Methods for examining tissues, 52 
Methyl blue, 370, 824 
Methylated spirit, 777 
Metritis. 375, 384, 389, 502, 516, 546 
and endometritis, acute, 384 
chronic, 400 

a cause of anteversion, 502 
associated with cancer, 401 
course and prognosis, 405 
diagnosis and physical signs, 404 
differential, 405 
from cancer, 405 
from pregnancy, 405 
from rectal disease, 405 
from small fibroids, 405 
divisions of, 402 
etiology. 402 
abortions, 402 
cellulitis, 402 
congestion, 402 
contusions from pessary, 403 
inflammation, 402 
lacerations of the cervix, 403 
micro-organisms, 391 
retention of placenta, 402 
subinvolution, 402 
symptoms, 403 
leukorrhea, 403 
menstrual disturbances, 404 
sterility, 404 
synonyms of, 400 
treatment, 405 

abdominal binder, 406 

amputation of the cervix, 408 

counterirritants, 407 

dilatation and curetment, 408 

douches, 406 

drainage of uterus, 410 

Emmet's operation, 408 

ergot, 406, 407 

exercise, 406 

extirpation of uterus, 410 

hip baths, 406 

medicated baths and waters, 

406 
pessary, 406 
preventive, 405 



Metritis, chronic, treatment, punc- 
turing and scarifying the cer- 
vix, 408 
repair of lacerations, 405 
rest, 406 

Schroder's operation, 408 
tampons, 408 
Weir Mitchell's, 411 
diagnosis, 404 

differential, between septicemia 
and sapremia, 387 
infection, how favored, 384 
involving the peritoneal coat, 386 
localized points of infection, 387 
parenchymatous, 374, 400 
pathologic alterations in, 384, 401 
prognosis, 389 
sapremic, 385 
septicemic, 385 
symptoms of sapremia, 386 

of septicemia, 387 
treatment, 389 
hot douches, 390 
Marmorek's antistreptococcic se- 
rum, 390 
prophylactic. 389 
varieties and their source, 385 
Metrorrhagia, 18, 255, 330, 403, 567 
Microblasts, 83 
Microcysts, 857 
Microcytes, S;^ 
Microcytosis, 83 

Micro-organisms, 138, 327, 328, 349, 
355. 362, 390, 441, 618 
as a cause of inflammation of the 
genito-urinary tract, 327 
Microscope, 48 
Microscopic examination of a fresh 

specimen, 77 
Microtome, freezing, 52 
Micturition, frequent, 667 
and painful, 91 
causes of, 18 
Migraine, 215 

Milk a basis for diet in pruritus, 342 
Milliamperemeter, 151 
Miscarriage, 13 
Moles and cysts of the uterus, 742 

tubal, 588 
Mons veneris, 159 
Monsell's salt, solution of, in gh^cerin, 

337 
Morcellement, 712 
Morgagni. columns of, 195 

hydatid of, 191, 853, 859 

sinuses of, 195 
Morphin, 116, 117, 134, 369, 427, 439, 
609, 828, 851 

sulphate, 116, 828 
Mortality of ovariotom^^ 922 
Motor and sensory paralysis, 15 
Mucilage, 777 
Mucometra, 742 



INDEX. 



949 



Mucosa, uterine, alterations of, during 

menstruation, 183 
Mtiller, canal of, 226, 859 

duct of, 157,224,230, 231,232,235,326 
diverticulum of, 230 
Miiller's dirt, 82, 

flmd, 777 * 

Multilocular cysts, 869 
Murphy button, 919 
Muscles, 165 

bulbo-cavernosus, 167, 192, 292, 346 

coccygeus, 170, 292 

erector clitoridis, 165 

ischio-coccygeus, 170 

levator ani, 170, 292, 297, 305, 574 

obturator coccygeus, 170 

obturator internus, 170 

of Guthrie, 192 

pelvic diaphragm, 170 

perforations of, 171 
pubo-coccygeus, 170 
transversus perinei, 170, 292 
Myoma of the bladder, 643 
Myomata, uterine, 650, 687, 806, 897 
complications of, 687 
ascites, 687 

disease of the tubes, 688 
inflammation, 687 
ovarian hematoma, 689 
pregnancy, 690 
course and prognosis, 693 

cystic degeneration in, 695 
death from chronic peritoni- 
tis, 696 
from disease of kidneys, 696 
from heart failure, 696 
from inflammation and 

gangrene, 696 
from rupture of C3'sts, 696 
from shock, 696 
from uremia, 696 
in heart affections, 695 
influence on climacteric, 695 
malignant degeneration, 695 
mortification and gangrene of 

tumor, 695 
mummification, 695 
perforations of neighboring 

organs, 696 
rupture of pedicle, 695 
degeneration of, 654, 681 
adenom^'omatous, 654 
amyloid, 683 
atrophy, 682 
calcification, 654, 682 
colloid myxomatous, 654, 683 
edema (hematoma), 654, 682 
fibrocystic tumors, 654, 682 
inflammation, suppuration, and 
gangrene, 684 
from compression, 684 
from injury, 684 
from septic infection, 684 



Myomata, uterine, degeneration of, 
lymphangiectatic, 654 
malignant, 686 
metabolism, 682 
sarcomatous, 654 
telangiectatic, 654 
diagnosis, 671 

consistence of the tumor an im- 
portant factor, 672 
differential, 674 
from abortion, 674 
from carcinoma, 674 
from desmoid tumor of ab- 
dominal walls, 674 
from displaced ovaries, 674 
from displaced uteri, 674 
from extrauterine pregnancy, 

674 
from floating kidney, 674 
from glandular ovarian cyst , 
.674 
from inversion, 674 
from pelvic infiltrations, 674 
from pregnancy, 674 
from sactosalpinx, 674 
from sarcoma, 674 
from subinvolution with en- 
dometritis, 674 
• etiolog}^ of, 664 

influence of age, 665 
of heredit}^ 666 
of irritation, 664, 666 
of menstrual congestion, 666 
of sexual irritation, 664, 667 
influence of, on conception, 690 
on labor, 693 
on pregnancy, 692 
pregnancy on m3^oma, 691 
microscopic appearance of, 652 
multiplicity of, 651 
necrosis, 657 

pathologic anatomy of, 652 
consistenc3^ 652 
mixed growths, 686 - 
carcinoma, 686 
enchondroma, 686 
myocarcinoma, 687 
myochondroma, 686 
myosarcoma, 687 
osteoma, 686 
sarcoma, 686 
vascularity, 652 
size of, 662 
structure of, 652 
symptoms of, 667 

abdominal cramps, 667 
anemia, 668 

apparent inflammation of blad- 
der, 667 
cachexia, 671 
constipation. 667 
dilatation of ureter and pelvis 
of kidney, 672 



950 



INDEX. 



Myomata, uterine, symptoms of, dis- 
placement of the uterus, 668 
fissure of anus, 667 
frequent micturition, 667 
growths filling up internal os, 

669 
hemorrhage, 667, 668 

associated with peduncu- 
lated polypi, 668 
hemorrhoids, 667 
hydronephrosis, 672 
inability to evacuate urine, 667 
increase of menses, 668 
itching and burning of anus, 

667 
leukorrhea, 669 

marked retention of urine, 667 
metrorrhagia from rupture of 

veins, 668 
pain, 667, 669 

pressure upon nerves and ves- 
sels, 668 
prolapse of rectum, 667 
pulmonary emboli, 696 
renal calculi, 672 
retention of gas, 667 
sacculation of the kidney, 670 
sloughing and gangrene, 668 
sterility, 670 
tympanites, 667 
varicose veins of anus and 

vulva, 667 
vesical tenesmus, 670 
treatment of, 696 
electric, 700 
Apostoli's, 701 
antisepsis, 702 
contraindications, 703 
acute nephritis, 704 
colossal tumors, 704 
fibrocystic tumor, 703 
heart failure, 704 
hysteria, 703 
intestinal catarrh, 703 
malignant degeneration 

of the tumor, 703 
pedunculated submucous 

fibroid, 703 
pregnancy, 703 
pus in the adnexa, 703 
very hard tumors, 704 
difficulties of, 702 
electro-puncture, 702 
frequency and duration of 

application, 702 
galvanism in, 152 
influence of, 701, 703 

in subserous tumors, 703 
interpolar method, ^04 
of negative pole within 

the uterus, 701 
of positive pole within 
the uterus, 701 



M^^omata, uterine, treatment, electric, 
Apostoli's, influence of, 
, polar influence, 704 
prevention of shock, 702 
general, 696 

binder or support, 697 
care in dress, 697 
mineral springs and bath, 
697 
medical, 697 
adrenalin, 700 
carbohydrates, 699 
constringents, 699 
mammary gland extract, 700 
oxytocics, 698 

promotion of calcareous de- 
generation, 699 
pulmonary edema induced 
by tincture of iodin injec- 
tion, 700 
thyroid extract, 699 
summary of, 734 
surgical, postoperative, 131 
bandaging limbs, 135 
enemata, 134 
hypodermocleisis, 135 
intravenous injections, 135 
rectal feeding, 134 
stomach tube, 134 
suppositories, 135 
in shock, 135 
palliative, 704 
radical, 704 
route, abdominal, accidents, 

737 

and results, hemor- 
rhage, 737 

injuries of the hollow 
viscera, 737 
of the intestine, 739 
of the ureter, 738 

ventral hernia follow- 
ing, 723 
castration, 705, 718 

contraindications of, 



719 
difficulties of. 



71' 



vasomotor s^^mptoms 
resulting from, 719 
enucleation, 720 

advantages of, 720 
hysterectomy, complete, 
or pan-hysterec- 
tomy, 729 
advantages of in- 
traperitoneal treat- 
ment of stump, 723 
Koeberle's operation, 723 
partial, or supra-vag- 
inal amputation of 
uterus, 723 
ligation of vessels, 719 
myomectomy, 720 



INDEX. 



951 



Myomata, uterine, treatment, surgical, 
route, vaginal dila- 
tation and curet- 
ment, 705 
dangers of curet, 707 
dilators, 705 
tents, 705 
incision of the capsule, 
708 
of the cervix, 708 
removal of the growth, 
709 
by enucleation, 710 
of interstitial tu- 
mors, 710 
of sessile tumors, 
710 
by hysterectomy, 716 
treatment of the 
Avound, 716 
by incision of the 

pedicle, 709 
by ligation of the 

vessels, 715 
by morcellement, 712 
by torsion, 709 
varieties of, 653 
cervical, 653, 662 

diagnosis, 671 
extramural, excentric, or sub- 
peritoneal, 660 
ascites with movable, 

662 
encapsulated, 662 
free, 662 
pedicle of, 662 
pedunculated, 660 
sessile, 660 
intramural or submucous, 654 
encapsulated, 654 
nonencapsulated, 654 
pedunculated, 655 
sessile, 655 
mural, interstitial, or centric 
_ growths, 654, 657 
circumscribed, general, 

658 
diffuse or gigantic, 658 
hypertrophy of the mu- 
cous membrane, 658 
local, 658 

N. 

Nabothian cysts, 377, 512, 746, 778 
Narcotics, 768, 818, 828 
Nausea and vomiting, 133, 899 
Needle, curved, 129, 825 

Freund's trocar, 800 

holder, 820 

Reverdin, 130 
Needles, 820 

straight, 129 



Neoplasms, 367, 622 

characteristics of benign, 622 

malignant, 639 
Nephrectomy for ureteral fistulas, 286 
Nephritis, 644, 649 

acute, 152 
Nerves, coccygeal, 209 

hypogastric plexuses, 209 

inferior hemorrhoidal, 209 

internal pudic, 209 

of the pelvic organs and structures, 
209, 210 

pudic, 210 

spinal and sympathetic, 209 

splanchnic, 210 
Nervous disturbances in menstruation, 

215 
Neuralgia, intercostal, 15 

lumbar, 149 

lumbo-abdominal, 149 

ovarian, 149 

visceral, 15 
Neurasthenia, 403 
Neuroma of vulva, 630 
Nitrite of amyl, 100 
Nitroglycerin, 118 
Nitrous oxid gas, 115 
Noma, 339 
Normoblasts, 83 
Notes, value of, 13 
Nubility, 212, 213 
Nuck, canal of, 159 

persistence of the, 232 
Nurse, duties of, 120 
Nutrition, disorders of, 16 
Nux vomica, 133 
Nymphae, absence of, 241 

defects of, 241 

hypertrophy of, 241 



O. 

Obesity, 16, 888 

Observation, importance of, ,12 

Obturator fascia, 170 

Odor, disagreeable, in cancer, 827 

Oil, bergamot, 57 

birch, 370 

castor, 451 

cedar, 77 

cod-liver, 407 

croton, 144, 407, 426 

erigeron, 569 

sandalwood, 360 

theobromae, 828 

tiglii, 144 
Ointment, belladonna, 346 

and camphorated lanolin, 369 
and ichthyol, 138 

benzoated zinc, 337 

betanaphthol in vaselin, 342 

bicarbonate of soda in vaselin, 82^ 

bismuth, 827 



952 



INDEX. 



Ointment, camphor, 343 
chloral, 343 
chloroform, 343 
condurango and vaselin, 829 
diachylon, 337, 338 
guaiacol in vaselin, 343 
ichth^^ol, 258, 346, 400 
iodoform, 146, 346 
lead acetate, 343 
mercurial, 337 
mercuric iodid, dilute, 426 
mercury, ammoniated, 337 
opium, 346 
sulphur, 342 
zinc oxid, 354 
Oligochromemia, 83 
Onanism, 92, 345 
Oophorectomy, 718 
Oophoritis, 421 

from gonorrheal infection, 421 
from septic infection, 421 
peri-, 421, 423 
serosa, 422 
Operation, arrangement for, 120 
assistants, 120 
closure of wound, 129 
clothing of patient, 120 
dressing, 131 
examination and preparation of 

patient for, no 
incision, 121 

crescent, 122 
peritoneum, toilet of, 125 
position of operator and assistants, 

120 
precautions during, 109 
preliminary details. 119 
preparation, special, in 
room and environment, no 
Operations, abdominal section, 114, 
121, 452 
Alexander's, modifications of, 
by Duret, 532 
by Edebohls, 532 
by Franklin Martin, 532 
by Goldspohn, 533 
by Newman, 532 
accidents and results of, 287 

calculi and calcareous concre- 
tions, 288 
inclusion of the ureter, 288 
peritonitis, 288 
primary hemorrhage, 287 
secondary hemorrhage, 287 
bladder, for carcinoma of, 649 
cureting for inflammation, 372 
extirpation of, for cancer, 649 
tumors, removal of, through the 
urethra, 644 
abdominal incision for, 645 
vaginal incision for, 645 
cervix, amputation of, 261, 492 
Baker's, 785 



Operations, cervix, amputation of, 
flap, double, 262 
single, 262, 384 
Hegar's, 785 
Schroder's, 384, 785 
vaginal, for cancer of uterus, 784 
Van de Warker's, 785 
with galvanocautery loop, 784, 
792 
incision for contracted os, 382 
laceration of, trachelorrhaphy 
(Emmet), 259, 383 
fistula, entero-vaginal, 291 
recto-vaginal, 273 
uretero - vaginal - uretero - cervical, 

vesico-uterine, 281 

hysterocleisis, 281 
vesico-utero-vaginal, 282 
vesico-vaginal, 268, 270 
colpocleisis, 278 
flap-formation, 275 
transplantation, 274 
Trendelenburg's operation, 

273 
for absent vagina, 234 
for malignant disease, 850 
for neoplasms, removal of growth 
by incision of the pedicle, 
709 
by morcellement, 712 
by torsion, 709 
ovary and tube, by abdominal inci- 
sion, castration, 705, 718 
for fibroid growths of ute- 
rus, 718 
for oophoritis, 427 
for prolapse of ovary, 566 
by ovariotomy, 903 

incomplete, for ovarian tu- 
mors, 916 
removal of, for inflammatory 
diseases, 452 
with uterus by vaginal inci- 
sion, 458 
shortening of infundibulopelvic 
ligament for fixation of, 566 
pelvic floor, for lacerations of, by 
denudation, Bischoff's, 
316 
Cleveland's, 313 
Dudley's, A. P., 314 
Emmet's, 309, 312 

Noble's modification of, 
311 
Freund's, 308 
Hegar's, 303 

Garrigues' modification 
of, 303, 495 
Heppner's, 307 
Hildebrandt's, 306 
intermediate operation. 



INDEX. 



953 



Operations, pelvic floor, for lacerations J 
of, by denudation, Lau- 
enstein's suture, 306 
Martin's, A., 308, 316 
Outerbridge's, 312 
primary, 296 
secondary, 799 
Simon-Hegar, 301 
by flap, 270, 275, 318 
Andrews', 317 
Duke's, 322 
Fritsch's, 321 
Harris', 317 
Noble, 321 
Ristine, 320 
Sanger's, 319, 320 
Simpson's, 321 
Tait's, 318 
for pregnancy, extrauterine, 
elytrotomy, 610 
incision, abdominal, after 
rupture, 613 
before rupture, 611 
vaginal, 612 
for prolapsus, Alexander's, 496 
Bald3'''s, 498 
colporrhaphy, anterior, 495 

posterior, 495 
Dudley's, E. C., 499 
Emmet's, 495 
Freund's, 497 
Garrigues-Hegar, 495 
Gilliam-Ferguson's, 496 
Hegar's, 495 
Hirst, 562 
Noble's, 499 
Ries, 496 
Wiggins, 498 
plastic, 140 
sacral, 641, 806 
Kraske's, 806 

modifications of,byBorelius,8 1 1 
by Hegar, 809, 810 
by Heinecke, 810 
by Herzfeld, 808 
by Hochenegg, 806 
by Kocher, 810 
by Levy, 810 
by Rydygier, 810 
by vSchede, 809 
by Schlange, 810 
by Wolffler, 810 
by Zuckerkandl, 810 
to construct a vagina, 233 
upon the uterus, for displacements, 
anteflexion, abdominal, 514 
vaginal, Dudley's, 512 
Nourse's, 513 
splitting posterior lip, 514 
anteversion, 503 

Sims' 503 
inversion of the uterus, abdom- 
inal incision, Thomas, 560 



Operations upon the uterus, vaginal 
incision, Kiistner's, 562 
retrodisplacements, abdominal, 
Alexander's shorten- 
ing of round ligaments, 
496, 530 
modified by Cassati, 533 
Doleris, 533 
Duret, 532 
Edebohls, 532 
Goldspohn, 533 
Martin, F., 532 
Newman, 532 
intraperitoneal shortening 
of round ligaments, 
Dudle3^'s (desmopyc- 
nosis), 535 
Mann's, 534 
W3- lie's, 534 
ventrofixation and ventro- 
suspension, 541 
vaginal, Bovee's, 546 
Diihrssen's, 545 
Freund's, 546 
Gottschalk's, 546 
Mackenrodt's, 545 
Pryor's, 546 
Ries's, 545 
Schucking's, 545 
Vineberg's, 545 
Wertheim's, 545 
for neoplasms, abdominal, 799 
castrations, 718 
enucleations, 720 
hysterectomy, modified by 
Bardenheuer, 801 
by Bishop, 733 
by Clark, 801 
by Crede, 801 
by Eastman, 801 
by Gubaroff, 801 
by Kelly, 801 
by Kuhn, 801 
by Mackenrodt, 803 
by Martin, A., 801 
by Polk, 802 
by Ries, 802 
by Rumpf, 801 
by Schroder, 803 
by Veit, 801 
by Werder, 802 
supravaginal or partial hys- 
terectomy, 723 
modified by Baer, 724 
by Bishop, 728 
by Gow, 724 
by Le Bee, 725 
by Marcy, H. O., 724 
by Pryor-Kelly, 727 
by Zweifel, 724 
vaginal hysterectomy, 1 1 1 , 
716, 790 
modified by Billroth, 792 



954 



INDEX. 



Operationsupon^the uterus for abdomi- 
nal neoplasms, vagi- 
nal hysterectomy, 
modified by Bottini, 
792 
by Bovee, 790, 795 
by Byrne, 796 
by Calderini, 792 
by Clark, 795 
by Corradi, 793 
by Czerny, 790, 792, 793, 

796 
by Downes, 797 
by Doyen, 792 
by Diihrssen, 794 
by Eastman, 797 
by Franck, 796 
by Fritsch, 792, 793 
by Frommel, 796 
by Kaltenbach, 793 
by Kelly, 793, 795 
by Landau, 792 
by Langenbeck, 790, 796 
by Leopold, 792 
by Liebmann, 793 
by Mackenrodt, 792, 795 
by Mikulicz, 792 
by Miiller, P., 793 
by Newman, 797. 
by Olshausen, 792, 793 
by Pawlik, 795 
by Pean, 796 
by Richelot, 796 
by Sauter-Recamier, 790 
by Schatz, 792 
by Schauta, 792 
by Schroder, 793 
by Schuchardt, 794 
by Tauffer, 792 
by von Teuffel, 793 
by Tuffier, 797 
by Veit, 793 
by Wecchi, 792 
by Winckel, 794 
by Winter, 796 
curetment, 705 
incision of capsule, 708 
of cervix, 708 
ligation of vessels, 715 
removal of growth, 709 
by enucleation, 710 
vulvar, Bartholinitis, 340 
epispadias, 248 
excision of elephantiasis, 629 
of urethral caruncle, 627 
of vulvar vegetations, 630 
extirpation of malignant disease 
of, 636 
Operator and assistants, 108 

position of, 120 
Opium, 324, 369, 427, 439, 450, 828 
with belladonna, 369 
with stramonium, 369 



Organ of Rosenm tiller, 186, 857, 859 

861 
Organs, interrogation of other, 13 
pelvic, abnormal communications 
of, 249 
Os, external, 179 
internal, 180 
tincae, 179 
Osteoma, 686 
Ovaralgia, 153 

Ovarial tubes of Pfluger, 188 
Ovarian abscess, 420, 441 
apoplexy, 191, 421, 567 
growths a cause of anteversion, 502 
hematoma, 191, 421, 441 
prolapse, 231, 565 

tumor, benign, complicated by ma- 
lignant disease of uterus, 773 
tumors, 366, 689, 806, 859 
adhesions of, 900 
characteristics of, 859 
classification of, 859 
dermoid, 873 

contents of, 873 
large, 859 

glandular cystomata, 864 
proliferating glandular, 864 
proliferous, 872 
proligerous, 864 
size of, 864 
structure of, 868 
areolar, 869 
multilocular, 860, 869 
cyst contents, 860, 871 
color of, 860, 871 
consistence of, 871 
specific gravity, 871 
unilocular, 860 
glandular proliferous, 861, 864 

pedicle of, 865 
papillary proliferous, 861, 872 
parovarian, 875, 900 
contents of, 875 
dermoid, 861 
how distinguished from 

ovarian, 876 
hyaline, 861 
papillar3% 861, 872 
proliferating, 872 
specific gravity, 875 
weight of, 875 
small, 859, 861 

cysts of corpus luteum, 863 
residual, 861 

hydatid of Morgagni, 861 
simple or follicular (hy- 
drops f olliculorum) , 
862 
etiology of, 863 
specific gravity of con- 
tents, 862 
tubo-ovarian, 863 
adhesions of, 883 



INDEX. 



955 



of 



899 

ectopic 



887 



Ovarian tumors, complication of, 880 
inflammation and suppuration, 
883 
symptoms of, 884 
pregnancy, 885 
rupture, 880, 884, 917 
torsion of pedicle, 881 

differential diagnosis of 
acute, from gall-stone 
colic, 899 
from ileus, 899 
from perforation of in- 
testine, 899 
from perforation 

stomach, 899 
from peritonitis 
from renal colic 
from ruptured 
gestation, 899 
from ruptured ovariai 
cyst, 899 
symptoms, 883 
degenerative changes in the walls 
887 
atheromatous, 888 
calcification, 887 
fatty degenerations 
infarctions, 888 
diagnosis, 888 
differential : 

from ascites, 890 
from desmoid tumor of ab- 
dominal walls, 888 
from distended bladder, 890 
from extrauterine gestation, 

896 
from fecal accumulation, 890 
from hematometra, 898 
from hydramnios, 896 
from hydrometra, 898 
from inflammator}^ growths 

of tubes, 895 
from large abdominal tu- 
mors, 895 
from localized peritoneal ef- 
fusion, 893 
from obesity, 888 
from other abnormal collec- 
tions, 898 
from physometra, 898 
from pregnancy, 895 
from retroperitoneal growths, 

897 
from tumors of abdominal 

viscera, 895 
from tumors of broad liga- 
ment, 897 
from tympanites, 889 
from uterine fibroids, 897 
from uterine myomata, 897 
from ventral hernia, 889 
questions to be considered in. 



Ovarian tumors, diagnosis, questions 
to be considered in, 
exploratory incision, 
902 
puncture, 901 

danger and disadvan- 
tage of, 902 
etiology, 878 
natural progress, 879 
pedicle of, 865 
prognosis, 920 
solid, 876 

endothelioma, 878 
fibromyoma, 876 
weight of, 877 
gyroma, 877 
symptoms, 880 
treatment, 902 
electrolysis, 902 
extirpation, 902 
ovariotomy, 903 

causes of death after, 922 
hemorrhage, 922 
ileus, 922 
peritonitis, 922 
shock, 922 
tetanus, 922 
contraindications for, 904 
bronchial catarrh, 904 
gastro-intestinal catarrh, 

904 
intercurrent fevers, 904 
irrecoverable, disease of 
heart, 904 
of kidneys, 904 
of liver, 904 
of lungs, 904 
marasmus, 904 
nephritis, 904 
pulmonary tuberculosis, 

904 
valvular disease of heart, 

904 
visceral injuries during, 

918 
weakness from loss of 
blood, 904 
general considerations, 905, 
914 
closure of wound, 907, 

914 
drainage, 907, 914 
dressing, 907, 914 
incision of abdominal 

wall, 907 
instruments, 905 
management of pedicle, 

911 
operation, 906 
postoperative treatment, 

916 
puncture and evacua- 
tion of cyst, 907 



956 



INDEX. 



Ovarian tumors, treatment, extirpa- 
tion, ovariotomy, 
general considera- 
tions, removal of 
cyst and manage- 
ment of adhesions, 
910 
of pedicle, 911 
toilet of peritoneum, 916 
incomplete operation, 916 
indications for, 903 

compression of lungs, 904 
suppuration of cyst, 883 
symptoms of hemorrhage, 
904 
of ileus, 904 
of rupture of cyst, 904, 

917 
of uremia, 904 
torsion of pedicle, 898 
intestinal complications, 921 

volvulus, 921 
mortality of, 922 
prognosis, 920 
Ovaries, absent or rudimentary, 231 
accessory or constricted, 231 
anatomy of, 186 
axes of, 186 
color of, 187 

connection with infundibulopelvic 
ligament, 187 
with uterus and tube, 186 
displacement of, 231 
electricity in chronic inflammation 

of, 152 
Graafian follicles of, 189 
inflammation of, 56^ 
malformations of, 231 
situation of, 186 
size of, 187 
stroma of, 189 
supernumerary, 231 
tubes of Pfliiger, 188 
Ovariotomy, 903 

visceral injuries in, 918 
to bladder, 920 
to intestine, 918 
to rectum, 919 
to ureter, 920 
Ovaritis, 351, 398, 421 
Ovary, abscess of, 420 

apoplexy of, 191, 421, 425, 567 
bulb of, 207 
cancer of, 773 
carcinoma of, 877 

complications of, 880 
adhesions, 881 
ascites, 880 
distention of ureter and pelvis 

of kidney, 880 
edema, 880 
etiology of, 878 

acquired disposition, 879 



Ovary, carcinoma of, etiology of, age, 
879 
heredity, 879 
inflammation, 879 
trauma, 878 
natural progress of, 879 
symptoms of, 880 
cirrhosis, 422 
function of, 423 
hematoma of, 421 
inflammation of, 421 
acute, 421 
chronic, 421 
diagnosis of, 425 
gonorrheal, 421 
septic, 421 
symptoms, 424 

pain only constant, 424 
treatment, 425 

care in the use of drugs, 426 
ice-bag, 425 
removal of ovary, 427 
rest, 429 
ligament of, 186 
prolapse of, 231, 565 
sarcoma of, 855, 877 
Ovula Nabothi, 183, 377, 380 
Ovulation and menstruation, 213 

without menstruation, 217 
Oxygen, mixture of chloroform and, 

117 
Oxytocics, 698 
Oxyuris vermicularis, 63, 73 



P. 

Pain, 13, 19 

in myomata, 667, 669 
seats of, 19 
accessory, 20 

anal or perineal, 20 
pelvic, 20 
vaginal, 20 
principal, 19 
hypogastric, 20 
iliac, 19 
lumbar, 20 
sympathetic, 15 
Palpation, 98 
Panhysterectomy, 729 
Papilloma of the ovary, 622 

superficial, 872 
Papillomata of tube, 854 
of vagina, 639 
of vulva, 630 
superficial, 872, 900 
Paracentesis abdominis, 100, 10 1 
Paraffin, 55 

melted, 341 
Paralbumin in cyst contents, 871 
Paralysis, motor and sensory, 15 
Parametritis, 330, 430 



INDEX. 



957 



Parametritis chronica atrophicans cir- 
cumscriptum et diftusum, 432 
posterior, 432 
Parametrium, 200 
Parasites of genital tract, 61, 63 
animal, 73 
vegetable, 63 
Parauterine pouch, 199 
Paris, plaster-of-, injections of, 201 
Parotiditis, 137 
Parovarian phleboliths, 858 
tumors, diagnosis of, 900 
Parovarium, 172, 191 
description of, 191 
Pars intermedia, 167 
Parturition, 212, 252 
Patient, comfort of, 132 

examination and preparation of , no 
preparation of, for ovariotomy, 905 
Peat baths, hot, 548 
Pedicle, 865 

management, 911 
Pediculi, 27, 341, 342 
Pediculosis pubis, 63, 73 
Pelvic connective tissue, 200 
diaphragm, 170 
action of, 170 
floor, lacerations of, 291 
causes of, 292 
complete, 293 
degree or extent of, 293 
incomplete, 293 
results of, 294 
treatment of, 295 
perforations, 171 
infiltrations, 680 
inflammations, 430, 884, 921 
organs, study of, as a whole, 211 
displacements, 466 
Pelvis, plane of, 211 
Pencils, cocain, 346 
copper sulphate, 399 
iodoform, 114 
silver nitrate, 399 
zinc chlorid, 399 
sulphate, 399 
Penis captivus, 346 
Peptonized milk, 134 
Perforation of bladder, 899 
of intestines, 899 
of uterus, 254 
Perimetritis, 440 
Perineal muscles, 165 

bulbocavernosus, 165 
erector clitoridis, 165 
levator ani, 165, 292, 305, 311, 

469 
sphincter ani, 165 
transversus perinei, 165, 292 
fascia, 168 
operation for removal of uterus, 

813 

septum, 168 



Perineum, laceration of, 291 
causes of, 292 
degree or extent of, 293 
results of, 294 
treatment of, 295 

intermediate operation, 298 
primary operation, 297 
advantages, 297 
contraindications, 298 
secondary operation. See Lac- 
eration of the pelvic floor. 
muscles of. 165 
Perioophoritis, 421, 423, 440 
Perisalpingitis, 440 
Peritoneum, pelvic, 197 
depression of, 199 
division of pelvic cavity by, 200 
reflections of, 198, 199 
toilet of, 125, 916 
Peritonitis, 135, 351, 416, 430, 440, 
919, 922 
pelvic, 883, 885, 893, 899 
diagnosis, 447 

differential, from cellulitis, 448 
from pelvic hematocele, 447 
etiology, 440 

complications during parturi- 
tion, 443 
favored by appendicitis, 443 
following operation for urinary 

fistula, 288 
gonorrheal salpingitis, 449 
idiopathic, 440 
new pelvic growths, 442 
pelvic hematocele, 441 
sepsis, 443 
tubal disease, 441 
twisting of pedicle of ovarian 
C3'st, 442, 898 
pathologic anatomy, 444 

intraperitoneal abscess, 445 
suppurative peritonitis, 444, 

445 
prognosis, 448 
symptoms, 446 
treatment, 449 
medical, 450 
preventive, 449 
surgical, 451 

incision, abdominal, 452 

closure of the wound, 456 

sutures in, 456 
difficulty in adhesions, 

453 
dramage, 455 

postural, 455 
in collapse, 451 
intestinal injections of 

cathartics, 455 
irrigation, 463 
protection of general 

peritoneum, 454 
steps of operation, 452 



958 



INDEX. 



Peritonitis, pelvic, treatment, surgical, 
incision, vaginal, 451 
section, vaginal, and uterine 
castration, 458 
tubercular, 70, 893 
Periuterine inflammation, 154, 430 

phlegmon, 430 
Perivaginitis, 331 
Pessaries, 490, 524, 548 

use of, 490 

contraindications to, 527 
Pessary, 490 

bulb, 490 

cup, 491 

disc, 490 

Gariel, 268 

Gehrung, 490 

Grailey Hewitt, 490, 510 

Hodge, 525, 527 

Munde, 490, 525 

ring, 490 

Schultze, 525, 527 
figure-of-8, 527 
sledge, 527 

Smith-Hodge, 490 

Thomas, 490, 510, 525 

Zwank, 490 
Phenols, 827 
Phlebitis, 138, 387, 741 
Phlebohths, 858 
Phlegmasia, 672 
Phlegmon of the labia, 340 

periuterine, 430 
Physical signs, 14 

senses employed in determining, 2 2 
Physiology of genital organs, 212 
Physometra, 741, 898 
Picrocarmin, 777 
Picrolithio-carmin, 56 
Picrotoxin, 222 
Pin-worms, 341 

Placenta praevia in myoma, 692 
Placental polypus, 743 
Plaster, mustard, 133, 572 
Platelets, blood, 85 
Platinum wire electrode, 151 
Pledget, 822, 823 

cotton, 822, 823 

gauze, 820 
Plicse palmate, 183 
Plug, glass, 235 
Pneumococcus, 73, 90 
Pneumonia, 102, 741 
Podophyllin, 141 
Poikiloblasts, 83 
Poikilocytes, 83 
Poikilocytosis, 8^ 

Poison, diphtheric or venereal, 357 
Polypi, mucous, of the bladder, 642 
of the uterus, 742 

uterine, 19, 742, 753 
Polypus, fibroid, 657 

intermittent, 672 



Polypus of tubes, 854 

placental, 743 
Positions for examination, 23 

dorsal, 23 

erect, 27 

genupectoral, 25 

lateral, 24 

lithotomy, 459, 799, 813 

semi-prone or Sims', 24, 797, 806 

Trendelenburg, 26, 646, 799, 918 
Potassium bromid, 133, 342, 343 
chlorate, 407 
chloride, 83 
citrate, 439 
iodid, 141, 407, 408 
permanganate, 143, 827 
salts, 699 
Pouch of Douglas, 199, 201 
parauterine, 199 
pubo-vesical, 199 
subperitoneal, 200 
utero-rectal, 199 
vesico-abdominal, 200 
vesico-uterine, 199, 200 
Poultices, 338, 426 
Poupart's ligament, 201 
Powders, alum and sugar, 337 
aristol and desiccated alum, 337 
bismuth subnitrate, 337, 361 

and chalk, 354 
boric acid and tannin, 826 
charcoal and iodoform, 826 
compound licorice, iii 
iodoform, 146, 337, 346, 361 

and tannin, S37^ 354 
lycopodium, 337 
pepsin and salicylic acid, 824 
seidlitz, 141 
starch, 337 
talcum, 337 
Pregnancv, 152, 670, 682, 690, 691, 

774, 885, 895 
abdominal, 585 
complicating carcinoma, 774 

ovarian tumors, 885 
extrauterine, 582, 675, 896 

causes of, 582 

course and progress of, 585 

mummification, 596 

secondary rupture in, 594 

symptoms, 596 

varieties of, 584 
in bicornate uterus, 605 
ovarian, 584 
spurious, 605 

tubal. See Ectopic gestation, s^ 4, 585 
tubo-ovarian, 585 
tubo-uterine, or interstitial, 585 
with retroflexed uterus, 605 
Probe, Sims', 35 
uterine, 35 
whalebone, 35 
Procidentia, 295, 474 



INDEX. 



959 



Prolapse of ovary, 231, 565 
Prolapsus, or descent, 473 
bandages in, 489 
classification of, 474 
pseudo-prolapsus, 474 
utero-vaginal, 474 
vagino-uterine, 474 
complete or incomplete, 474 
complicating ovarian tumor, 880 
congenital, 230 
degrees of, 473 
first, 473 
second, 474 
third, 474 
diagnosis of, 481 

differential, from cyst in anterior 
wall of vagina, 484 
from cystocele, 481 
from elongated cervix, 482 
from enterocele, 485 
from fibroid potypus, 484 
from inversion of uterus associ- 
ated with inversion of vagina, 
484 
from rectocele, 481 
dress and hygiene as a cause, 476 
etiology of, 475 

abdominal growi;hs in, 477 
prognosis, 485 
symptoms of, 477 
cystocele, 478 
leukorrhea, 480 
rectocele, 478 
treatment, 488 
hygienic, 488 
mechanical, 489 
operative, 492 
uteri, congenital, 230 
varieties of, 474 
Proliferating glandular cysts, 864 
Proliferous cysts, 872 

papillary, 872 
Proligerous cysts, 864 
Protargpl, 337, 399 
Protection from infectious germs, loss 

of, 62 
Pruritus vulvae, 332, 341 
idiopathic, 341 
prognosis of, 342 
specific cause of, 341 
symptoms, 341 
treatment, 342 

guaiacol in, 343 
with cancer of the uterus, 769 
Pryor's operation for displaced uterus, 

546 
Pseudocyesis, 889 
Pseudomucin, 886 
Psoriasis vulv^, 636 
Puberty. 212 

changes associated with, 213, 214 

definition of, 212 

influence upon discharge, 22 



Puberty, precocious, 212 

retarded, or delayed, 213 

time of occurrence of, 212 
Pubovesical ligaments, 191 

pouch, 199 
Pudendal sac, 168 
Pudendum, 159 
Puncture, exploratory, 100, 696, 901 

of cvsts preliminarv to ovariotomy, 
908 
Purgation, 136, 828 

before ovariotom}-, 915 
Pyelonephritis, 363 
Pyelonephrosis, 102, 364 
Pyemia, 775, 883 
Pyocolpos, 241 
Pyocyanei, 61 
Pyometra, 410, 742, 842 
Pyonephrosis, 751 
Pyosalpinx, 351, 413, 445, 446, 448, 

689, 770, 895 
Pyrosis, 17 



Quassia, 342 

Quicksilver, 820 

Quinin, 134, 141, 381, 407, 451 



R. 

Reconstructives, 141 
Rectal douche, 143 

feeding, 134, 451 

touch, 31 
Rectocele, 27, 295, 309, 315, 478 
Rectovaginal fistula, 264, 266, 289 
Rectum, ampulla of, 195 

anal orifice of, 195 

anatomy of, 194 

crypts of, 195 

injury to, during operation, 919 
in vaginal h3"sterectomy, 798 

lymphatics of, 209 

mucous membrane of, 197 

urinary organs and, 191 
Red cells, normal number of, 84 
Reflexes, rectal, 17 

vesical, 18 
Remedies, specific, 141 
Renal calculus, 479 

coHc, 899 

dilatation, 670 
Residual cysts, 861 
Rest and exercise, 142 

treatment, 42Q 
Retractors, wooden, 821 
Retroflexed gravid uterus, 605 
Retroflexion of the uterus, 472, 514. 
See Retroversion. 
diagnosis of, 518 

differential, from adherent ova- 
rian growths, 520 



960 



INDEX, 



Retroflexion of the uterus, diagnosis 
of, differential, from fibroid 
growths, 520 
from pelvic inflammatory 
exudation, 520 
etiology of, 516 
examination in, bimanual, 520 

vaginal and rectal, 520 
immobile, 515 



pathologic, 515 
symptoms o"f, 516 
treatment, 520 
Retroperitoneal tumors, 897 
Retroposition of the uterus, 500 
Retroversion, 504 

an early stage of prolapsus, 504 
and retroflexion, treatment of, 520 
adhesions, 533 
desmopycnosis, 535 
in adherent uterus, 523 
in non-adherent uterus, 524 
intraperitoneal methods for, 

533 
methods for replacing the 

organ, 521 
operative, 530 

Alexander's operation, 530 
advantages, 533 
disadvantages of, 533 
massage, 524 
pessary in, 524 
Schultze's method, 524 
use of sound in, 522 
vaginal operations in, 544 
ventrofixation, 541 
advantages of, 543 
disadvantages of, 543 
ventrosuspension, 541 
diagnosis of, 506 
etiology of, 504 
symptoms, of, 505 
constipation, 506 
cystitis, 506 
. fissure of anus, 506 
hemorrhoids, 506 
inflammatory complications, 506 
interference with rectal circula- 
tion, 506 
menorrhagia, 505 
Rheostat, 151 
Rima pudendum, 159 
Rontgenic rays, 154 
Room and environment, no 
operating, no 
preparation of, no 
Rosenmiiller, organ of, 186, 191, 857, 

859, 861 
Round ligament, extraperitoneal 

method of shortening, 530 
Rubber gloves, 109 

skirt, 827 
Rubin and orange, 777 



Rupture of cystic tumors, 884, 904, 917 
ectopic gestation, 437 
uterus, 254, 887 
treatment of, 254 



S. 

Sacral resection, 806 
Sactosalpinx, 680 
Safranin, 55 
Saline, 391, 425, 851 

cathartic in suppurative peritonitis, 

439. 455 
Salol, 113, 268, 359, 851 

and aristol, 827 
Salpingitis, 351, 411, 546 

avenues of infection, 411 

cysto-adenosa 416 

diagnosis of, 419 

hematosalpinx, 414, 854 

hydrops tubae profluens, 415, 864 

h3'drosalpinx, or sactosalpinx, 413, 

854 
nodosa mistaken for myoma, 852 
pathological changes in, 414 
peri-, 419 
prognosis, 420 
pyosalpinx, 413 
symptoms, 418 
treatment, see Sec. 459 
Salts, alkaline, 370 
ammonia, 699 
benzoin, 268 
bromid, 141, 699 
cocain, 118 
Epsom, III, 141 
iron, 572, 632 
manganese, 142 
mercur}^ 114 
potash. 407, 699 
Rochelle, in, 141 
zinc, 823 
Sand-bag, 138 

Sand or peat baths, hot, 548 
Sandal-wood oil, 360 
Sanger's sutures, 319 
Santonin for pinworms, 342 
Sapremia, 385 
diagnosis of, 387 
prognosis, 389 
symptoms of, 386 
treatment of, 389 
Saprophytes, 329, 385, 843 
Sarcoma, 634, 641, 678, 686, 744, 780, 
836, 846, 855, 858, 877, 900 
diagnosis, 846 

differential, from carcinoma of 
uterine body, 849 
from chorioepithelioma, 850 
from chronic metritis, 847 
from fungous endometritis, 847 
from interstitial endometritis, 
847 



INDEX. 



961 



Sarcoma, diagnosis, differential, from 
mucous polypi, 847 
from senile endometritis, 846 
from subinvolution, 848 
from submucous m3-oma, 847 
from tuberculosis of endome- 
trium, 849 
microscopic examination in, ne- 
cessity of, 847 
duration of, 845 
etiology of, 841 
metastasis in, 845 
of ovary, 855, 877 
pathology of, 836 
recurrence, 849 
symptoms, 842 

cachexia, 842, 844 
discharge, 842 
emaciation, 844 
hemorrhage, 842 

increase of tumor after meno- 
pause, 844 
pain, 842 
treatment, 850 
operative, 850 
contrain ' " 
varieties of, 836 
of body, 836 
of cervix, 836 
of uterine wall, 836 
Scalpels, 124 
Schroder's operation, 399 
Schiicking's operation, 545 
Scissors, 830 
curved, 272 
Kuchenmeister's, 47 
Sclerosis, cervical. 379 
Scopolamin-morphin narcosis, 117 
Seats of pain, 19 

Secretion and fluids, collection of, 75 
from Fallopian tubes and uterine 
cavity, 20 
from vagina and vulva, 20 
Section, abdominal, 114 

antero-posterior vertical incision, 

465 
control of hemorrhage, 463 
dressings, 461 
pus sacs in, 463 
reason for preferring, 805 
steps of operation, 459 
vaginal, 458 
cutting, 55 
Segregator, 96 

Seidlitz powder for nausea, 133 
Senna. 342 

Sepsis, 102, 411, 662, 775, 784, 802 
Septicemia, 385, 387, 443, 611, 740 
puerperal, 64 
symptoms, 386 
treatment, 389 
Serum, antistreptococcic, 390 
Sessile fibroid, 66^ 
61 ^ 



Shock, 102, 702, 740, 922 
Sight, use of, in diagnosis, 22 
Signs, physical, 22 

senses in study of, 22 
Silk, carbolized, 724 
iodoform, 106 

ligatures and sutures, 106, 724, 919 
Silkv,-orm-gut, 108, 269, 296, 300 
Silver nitrate, mitigated stick of, 361 
soHd stick of, 145, 343, 384 
salts, 648 
Simple cysts, 862 
Simpson's operation in laceration of 

perineum, 321 
Sinistroflexion, 546 
Sinuses of Morgagni, 195 
Sinusoidal current, 153 
Sitz-bath, 143, 826 

hot, 336, 353, 426, 548 
Skene's ducts, 163 

follicles, 355 
Slides, 77 

Sloughing fibroids, 114 
Smegma bacillus, 72 
Smell, how used, 22 
Soap, green, 105 

potash, 338 
Sodii bicarb., 823 
Sodium carbonate, 8;^ 
chloride, 83 
phosphate, 83 
Solutions, acetic alum, 826 
acid, boric, 139, 336, 353, 
372,646 
carbolic, no, 139, 258, 

370,633, 724 
chromic, 399 
chromitmi trioxid, 399 
hydrochloric, 109 
hydrocyanic, 343 
nitric, dilute, 268 
oxalic, 109 
sahcylic, 824 
sublimate, no, 113, 114 
adrenalin chlorid. 125, 369, 821, 913 
alum sulphate. 354 
aluminum acetate, 573 
antip3'rin, 125, 337 
antiseptic, no, 399 
argyrol, 258, 337^ 37^ 
atropin, 139, 918 
bichlorid, 104, 109, in, 259, 390, 

bismuth in gh-^cerin, 354 

boroglycerid (50 per cent.), 258, 399 

bromin (alcoholic), 792 

caustic soda, 53 

chloral, 346 

chloroform in glycerin, 343 

cocain, 118, 133, 343. 359. 369. ^3^ 

corrosive sublimate, 54, 109 

creolin, 143, 290 

ergone, 918 



37°^ 371. 

336^ 343: 



962 



INDEX. 



Solutions, ergotin, 138 
ferripyrin, 125 
Flemming's, 54 
formaldehyd, 633, 822 
formalin, 53, 259, 263, 325, 390, 392, 

399. 511. 791. 821 
Fowler's, 133 
Gabbet's, 365 
Harrington's, 109 
Hermann's, 54 
hydrastis, fl. ext., 360 
ichthyol, 147, 340 

in gl3^cerin, 147, 258, 383, 398, 400 
lanolin, 383 
iodin. tinct. co., 337 
iodoform in ether, 114, 259, 383, 776 
iron, 409, 503, 647 

perchlorid, 700 

persulphate, 632, 823 
Kaiserling's, 59 
Labarraque's, 112 
lead acetate, 337, 382 
liquor aluminii acetici, 648 
lysol, 353 

magnesium sulphate, 455 
mercurol, 370, 398 
Monsell's salt in glycerin, 337 
morphin, 135 
normal salt, 259 
potassium acetate, 53 

bromid, 342 

dichromate, 107, 777 

permanganate, 109, 347, 398 
protargol, 347. 3 70, 39^ 
pyoktanin, 370, 825 
pyroligneous acid, 258 
saline, 263, 913, 916 
saturated aqueous, of acid fuchsin, 

79 
meth}'! green, 79 
orange G, 79 
Sherrington's, 81 

silver nitrate, 146, 258, 337, 340. 
343. 347. 354, 360, 371, 372, 399, 
825 
sodium bicarbonate, 259, 399, 823 
chlorid (normal), 125, 259, 390, 

399, 455, 614, 794, 913 
hyposulphite, 338 
strychnin, 141 

sublimate, 54, 104, 106, 107, 109, 
III, 263, 325, 336, 372, 390, 630 
alcoholic, 790 
thymol, 112, 143, 827 
Toisson's, 81 

zinc chlorid, 146, 258, 340, 823 
sulphate, 354, 382, 383 
Sound, 34, 35 
dangers of, 523 
perforations of uterus by, 37 
precautions in use of, 37 
replacement of uterus by, 522 
Simpson's, 35 



Specimen, the, 76 

Specimens and slides, preservation of 

gross, 58 
Specula, urethral, 95, 644 
uterine, 37 

varieties of, Edebohls', 42 
Goodell's, 39 
Higbee's, 39 
Nelson's, 39 
Nott's, 39 

Sims' self -retaining, 41 
tubular, 37 
univalve or duck-bill, 41 

method of use of, 41 
valvular, 38 
Talley's, 39 
Sphincter ani, 166 
extemus, 167 
internus, 167 
laceration through, 292 
tubas, 185 
vaginas, 167, 176 
vesicae, 193 
Spigelia, 342 
Spina bifida, 230 
Spinal anesthesia, 119 
Spirilla of Obermeyer, 90 
Sponge packs, 615 
Sponges, 105, 617 

definite number of, 120, 466, 906 
gauze pads for, 105 
Spongiopilin, 426 
Spray, no 
Springs, Elster, 697 
Franzenbad, 697 
Halle, 697 
Kreuznach, 697 
Tolz, 697 
Stain, Ehrlich triacid, 78, 79 
fuchsin-resorcin, 58 
hematoxylin, 56 
Jenner's, 79 
orcein, 58 

picroHthio-carmin, 56 
Wright's, 79 
Staining of tissue, 56, 78 

fixation for, 78 
Staphylococcus albus, 63, 328 

pyogenes aureus, 63, 90, 328, 349, 
362, 441 
Static machine, 154 
Steel electrode, 151 

Sterility, 18, 379, 404, 438, 448, 504, 
670, 690 
a cause of ectopic gestation, 583 
Sterilization methods, 103 
boiling, 103 
fractional, 103 
heat, 103 
steam, 103 
of dressings, 108 
of instruments, 104 
of ligatures and sutures, 103, 106 



INDEX^ 



963 



Sterilization of sponges, 105 

Sterilizer, Arnold's, 103 

Stethoscope, 99 

Stitch, crown, 311 

Stomach-tube, 134, 136 

Stovain, 118 

Stramonium, 369 

Streptococcus pyogenes, 61, 63, 64, 90, 

328, 330, 441 
Stricture, rectal, 267 
Strontii salicylate, 369 
Strychnin, 100, 119, 381, 391, 407, 609, 

906, 915, 918 
Styptics, 147, 784 

Subinvolution of uterus, 400, 516, 679 
Subperitoneal growths of uterus, 660 
Sulphate of zinc, 146, 572 

crayons, 146 
Sulphonal, 343 
Suppositories, 828 

belladonna ext., 369 

cocain hydrochloride, 369 
in cacoa-butter, 360 

ice, 135, 581 

lead acetate, 354 

opium ext., 324, 369 

quinin, 391 

santonin, 342 

tannin and iodoform, 354 

zinc oxid, 354 
Suture, ligature and, material, 106 
Sutures, 129, 456 

catgut, 259, 269, 542, 711, 735 

cobbler, 724 

figure-of-8, 313, 456 

interrupted, 129 

Lembert, 455, 725 

mattress, 825 

perineal, 296, 303 

purse-string, 733 

quill or bar, 302 

rectal, 303 

removal of, 139 

silk, 269, 291, 542, 544 

silkworm-gut, 269, 270, 291, 542, 

. 544 
silver wire, 129, 269, 291, 497, 542, 

544, 804 
Stolz's purse-string, 494, 550 
vaginal, 303, 306 
Symptoms, general, 15 

anemia, 16 

chlorosis, 16 

disorders of nutrition, 1 6 

gastric, 15 

hemorrhage, 18 

pains, sympathetic, 15 

paralysis, motor and sensory, 15 

visceral, 15 
genital, 18 
local, 16 
objective, 22 
subjective, 14 



Syncope and death after removal of 

large tumors, 918 
Syncytio malignum, 832 
Syphilis and chancroid, 70 

organism of, 63 
Syringe, bulb, 258 
fountain, 258 

hypodermic, methods of infection, 
^38 . . 
precautions m use of, 138 
uterine, 126 

T. 

Table, Chadwick's, 23 

suitable, 23 
T£enia echinococcus, 74 
Tait's operation in laceration of peri- 
neum, 318 
Tamponade in cancer, 826 
Tampons, absorbent cotton, 146, 258, 
383, 502 

borated, 147, 258, 343, 826 

boroglycerid in glycerin, 258, 408 

carbolic acid, 147, 258, 408 

carbohzed, 343 

cotton and gauze, 258, 408 

gauze, 146, 258, 851 

glycerin, 258, 399, 548 

ichthyol in glycerin, 258, 408 
in lanolin, 258, 354, 408 

iodoform gauze, 258, 400, 503, 825, 
826 

iron chlorid, 824 

lamb's wool, 146 

saturated with fat and oily mix- 
tures, 827 

sublimated, 258, 343 

sulphurous acid and boroglycerid, 

343 

thymolized, 258 
Tannin, 147, 723, 826 

glycerite of, 147 
Tapeworm, dog, 74 '^ 

Tapping, or paracentesis abdominis, 

100. lOI 
Temperature, elevation of, 796, 921 
Tenaculum, 43 
Tents for dilatation, 44, 571, 735 

laminaria, 44, 114, 258, 571, 705, 735, 
776 . 

preparation of, 44 

sponge, 44, 114, 57 r 

sterilization of, 511 

tupelo, 44, 114, 571, 792 

use of, 114 
Teratoma, 874, 900 
Tetanus after abdominal hysterec- 
tomy, 741, 803, 922 
Therapeutics, 102 

classification of, 102 

extension of, 102 

local, 143 



964 



INDEX. 



Thermo-cautery, 268, 345, 346, 361, 
384, 460, 630, 633, 636, 647, 790, 
792, 820, 830 
Paquelin, 384, 647, 795, 824 
Thirst, 133 
Thrombi from exploratorv puncture, 

696 
Thrombus, vulvar, 573 

vulvo-vaginal, 574 
Thyroid extract, 141, 510, 699 
Tincture, Churchill's, 146 
green soap, 1 1 1 
hyoscyami, 268, 370 
of aconite, 336 
of belladonna, 369 
of capsici, 407 
of chlorid of iron, 146, 399 
of cinnamon, 572, 698 
of iodin, 114, 133, 144, 145, 146, 
382, 383, 399, 409, 426, 503. 
648, 700, 705, 707, 776, 822 
and carboHc acid, 145 
and creasote, 257 
of nux vomica, 133 
of opium, 132, 396 
valerian, 132 
Tobacco smoking for pruritus, 343 
Toilet of the peritoneum, 125, 916 
Tonics, 381 
Torsion of the pedicle, 881, 898 

of the uterus, 501 
Touch, bimanual. 30 
employment of, 22 
information afforded by, 28, 29 
simple, 27 
Trachelorrhaphy, 259 
Transversus perinei muscle, 170 
Traumatism, cause of inflammation, 
328 
of retroversion, 505 
Traumatisms, causes productive of, 
250 
general consideration of, 250 
injuries of the genital organs, 250 
treatment of, 251, 252 
Trays, instrument, 905 
Treatment following operations for 
malignant disease, 850 
for absent vagina, 234 
for acute inflammatory difflculties, 

144 
for Bartholinitis, 340 
for carcinoma of the bladder, 649 
of the tube, 855 
of the uterus, 784 
of the vulva, 636 
for cellulitis, pelvic, parametritis or 

periuterine phlegmon, 438 
for chorioepithelioma, 834 
for chronic pelvic troubles, 146 
for cystitis, 368 
acute, 368 
chronic, 368 



Treatment for cystitis, gonorrheal, 366 
for C3-sts of broad ligaments, 857 

of the vagina, 638 
for defects of clitoris, 242 
for displacements, anteflexion, 512, 

547 

anteversion, 502, 547 

appendages, 566 

lateral flexion, 547 

retroflexion, 520, 547 

retroversion, 520, 547 
for echinococcus cysts, 857 
for edema of vulva, ^^8 
for elephantiasis vulvce, 629 
for endocervicitis, chronic cervical 

catarrh, cervical endometritis, 381 
for epispadias, 248 
for epithelioma of vagina, 641 
for erectile or vascular tumors of the 

vulva, 627 
for extrauterine pregnancy, 609 
for fibroid tumors and polypi of 

vagina, 639 
for fibrom3^omatous tumors of the 

uterus, 696 
for fistula, 267 
j for gangrene of vulva, 339 
I for gas cysts of vulva, 623 
[ for hematocolpometrosalpinx, 238 
for hematocolpos, 238 
for hematometra, 238 
for hematosalpinx, 238 
for hematuria, 568 
for hemorrhage, genital, 572 

periuterine, 580 
for hydatid cysts of uterus. See 

Chorioepithelioma. 
for hydrocele, 625 
for injuries of the body of the uterus, 

of the cervix uteri, 257 
for internal hemorrhage, 135 
for inversion of the uterus, 557 
for kraurosis vulvas, 345 
for lacerations of pelvic floor, 257 
for liquid cysts of the vulva, 625 
for malignant disease of vulva, 636 
for metritis and endometritis, acute, 
398 
chronic, 398 
for mucous polypi of bladder, 644 

of uterus, 743 
for myoma of bladder, 644 
for oophoritis, 425 
for ovarian tumors, 902 
for papillomata or condylomata, 630 
for perioophoritis, 449 
for perisalpingitis, 449 
for peritonitis, pelvic, parametritis, 

perisalpingitis, or perioophoritis, 

449 
for physometra, 742 
for pruritus vulvse, 342 



INDEX. 



965 



Treatment for salpingitis. See sec. 

459 
for sarcoma of bladder, 644 

of tubes, 855 

of uterus, 850 

of vagina, 641 

of vulva, 636 * 
for shock, 135 

for tumors of the vulva, 630 
for tympanites, 134 
for ureteritis, acute, 373 

chronic, 373 
for urethral caruncle, 627 
for urethritis, 359 

acute catarrhal, 359 

chronic catarrhal, 359 
for vaginal hematoma or thrombus, 

for vagimsmus, 346 
for vaginitis, 353 

senile, 354 

specific, 353 
for villous polypi of bladder, 644 
for vulvar hematoma or hematocele, 

575 
for vulvitis, 336 
general, 337 
medical, 337 
post-operative, 131 
general, 140 
medical, 140 
Trendelenburg posture, 452, 646, 724, 

799. 918 
Triangular ligament, 168, 191 
Trichiasis, 341 
Trifacial nerve, 15 
Trigone, 192 
Trional, 343 
Triticum repens, 370 
Trocars, 100, 905 
Tubal abortion, 586 

ostia, accessory, 231 
Tuberculosis of endometrium, 849 

of genital tract, 69 
Tubes, Fallopian, absent or rudimen- 
tary, 230 
accessory tubal ostia, 231 
anomalies in length of, 231 
irrigating, 112 
malformations of, 230 
Tubo-ovarian cysts, 420, 861 
Tumors, benign, 621 

bladder, carcinoma, 649 
myoma, 643 
polypi, mucous, 642 
villous, 642 
broad ligament, carcinoma, 858 
echinococcus, 857 
fibroma, 858 
lipomata, 858 
parovarian varicocele, phlebo- 

liths, 858 
sarcoma, 858 



Tumors, cervix, fibromyoma of, 662 
desmoid, 98, 888 
erectile or vascular, 625 
extrauterine pregnancy, 582 
Fallopian tubes, 852 
carcinoma, 855 
chorioepithelioma malignum, 

856 
dermoid, 853 
enchondromata, 853 
fibrocyst, 853 
fibroma or myoma, 852 
hematosalpinx, 238 
hydatid of Morgagni, 853 
hydrosalpinx, 419 
lymphangiectasis, 853 
lymphangiectatic cysts, 853 
papillomata, 621, 854 
. pyosalpinx, 689 
sarcoma, 621 
serous, 853 
fecal, 890 
fibrocystic, 152 
genital, 621 

classification of, 621 
intraligamentary, 569, 879, 880 
malignant, 621, 743 
ovarian, 855, 859 

characteristics of, 859 

cystic, areolar, 869 

cysts of corpus luteum, 863 

dermoid, 873 

glandular proliferating cystoma, 

864 
hydatid of Morgagni, 861 
intraligamentary, of ovary and 

uterus, 569 
multilocular, 860 
papillary cystadenoma, 870 

proliferous, 864 
parovarian, 875 
proligerous, 864 
sessile, 865 

simple or follicular, 862- 
solid, 876 

carcinoma, 877 
endothelioma, 878 
fibromyoma, 876 
gyroma, 877 
residual, 861 
retroperitoneal, 897 
sarcoma, 877 

carcinomatosum, 877 
teratoma, 874, 900 
tubo-ovarian, 420, 861, 863 
unilocular, 859, 863 
uterine, carcinoma, 649, 686. 744 
enchondroma, 686 
fibrocystic, 152, 682 
fibromyomata, 650 

interstitial, mural or centric 
fibroids, 657 
myocarcinoma, 687 



966 



INDEX. 



Tumoi-s, uterine, myochondroma, 686 
myosarcoma, 687 
osteoma, 686 
puerperal, 741 

hematometra, 742 
hydatid cysts, 742 
hydrometra, 742 
physom.etra, 741 
sarcoma, 686 
submucous fibroids, 654 
subperitoneal growths, 660 
vaginal, cysts, 622 

fibroid tumors and polypi, 638 
malignant neoplasms, 639 
papillomata, 639 
vulvar, 622, 629 
cysts, blood, 629 
gas, 623 
liquid, 624 

gland of Bartholin, 629 
hydrocele, 624 
sebaceous cysts, 629 
simple, 630 
elephantiasis, 628 
enchondroma, 633 
epithelioma, 633 
erectile or vascular, 625 
fibroma, 633 
lipoma, 633 
myxoma, 633 

papillomata or condylomata, 630 
sarcoma, 633 
Tunica albuginea, 188 
fibrosa, 189 
propria, 189 
Turpentine, 699 
Tympanites, 134 
Typhoid bacillus 
Tyrosin in cysts. 



71. 
901 



388 



U. 

Ultraviolet rays, 155 
Unilocular cysts, 860 
Urachus, open, 249 
Urea in cysts, 901 
Uremia, 17, 769, 771 
Ureter, accessory, 249 

cancer of, 751, 795 

catheterization of, 92, 795 

description of, 194 

disease of, 341 

cause of pruritus, 341 

exploration of, 91 

inclusion of, in fistulse operations, 
288 

injury of, 738, 798, 806, 812, 852 

involved in cancer, 769 

irregular exit of, 249 

ligament of, 194 

palpation of, 93 

transplantation of , into bladder, 806, 
920 



Ureter, transplantation of, into rec- 
tum, 248 
Ureteritis, 372 

acute, 372 

symptoms of, 372 

causes of, 372 

chronic, 373 

symptoms and signs of, 373 

treatment of, 373 
Ureterovaginal-ureterocervical fistulae, 

283 
Urethra, 191 

absent, 246 

atresia of, vagina and, 246 

attachments of, 191 

cysts of, 637 

diameter of, 191 

dilatation, 91 

dimensions of, 191 

exploration of, 91 

external meatus, 163, 192 

follicular inflammation, 356 
treatment, 359 

granular erosion of, 359 
treatment, 360 

hyperemia of, 354 

use of catheter in, 355 

inflammation of, 92 

length of, 191 

mucous membrane of, 192 

ulceration of, 357 
symptoms, 357 
Urethral caruncle, 27, 355, 626 

endoscope, 92 

specula, 95 
Urethritis, 354 

acute catarrhal, 355, 356 
diagnosis, 356 
symptoms, 356 

chronic interstitial, 354 
symptoms, 356 

follicular, 356, 361 
symptoms of, 357 
treatment of, 361 

gonorrheal, 359 

treatment, 359 

varieties, 354 
Urethrocele, 499, 638 
Urethroscope, 94 
Urethro-vaginal fistula, 264, 279 
Urinary organs and rectum, 191 
Urine, diminution of, from pressure of 
tumor, 880 

examination of, 92 

incontinence of, 92, 265, 365 

of separate kidneys, 364 

retention of, 362 
Urogenital sinus, 157, 246 
Urotropin, 369 

Uteri, accessory, or trifid, 230 
Uterine body, carcinoma of, 752 

cavity, antisepsis of cervix and, 113 

myomata, electricity in, 152 



INDEX. 



967 



Uterine polypi, 19 
Utero-rectal culdesac, 199 
Uterus, absent, 228 
accessory or trifid, 230 
anatomy of, 178 

anteflexion of, 472, 506. See Ante- 
flexion. 
ante version of, 501. See Ante- 
version. 
ascent of, 472 

diagnosis of, 473 
atresia of, 227 
axis of, 211 
bicornis, 225 
arcuatus, 225 
unicollis, 225 
bifidus, 225 
biforis, 228 
bilobularis, 225 
bipartitus, 228 
cancer of, 22, 649 

carcinoma of, 649, 744. See Car- 
cinoma. 
descent or prolapse of, 473 
didelphys, 225 
dilatation of, 43 
by tents, 44 
gradual, 43 
dimensions of, 178 
dislocation of, 500 
anteposition, 500 
latero-position, 500 
retroposition, 500 
displacements, 471 

classification of, 471 
divisions of, 178 
double, 225 
fetal, 229 
fibromyomatous tumors of (myo- 

mata), 650. See Myomata. 
fixation and traction upon, 43 
forces sustaining, 467 
fundus of, 178 
hydatid cysts of, 742 
cystic mole, 742 
incarceration of retrofiexed gravid, 

366^ 
infantile, 229 
inflammation of, 374 
acute, 384 

causes of, 384 
chronic, 375, 394 

areolar hyperplasia, 379 
cervical catarrh, 375 
diagnosis, 380 

differential, from endo- 
metritis, 381 
from ovules of Na- 

both, 377, 380 
from papillary ero- 
sion, 376 
from vaginal inflam- 
mation, 380 



Uterus, inflammation of, chronic, 
cervical catarrh, symptoms, 379 
classification of, 374 
complicated with retroflexion, 379 
diagnosis of, 380 
diphtheric, 375 
gonorrheal, 375 
micro-organisms, 375 
physical signs of, 380 
prognosis of, 381 
relief of congestion in, 383 
saprophytic, 375 
septic, 375 
symptoms of, 379 
syphilitic, 375 
treatment of, 381 
constitutional, 381 
curet, 384 
douches, 381 
electricity, 384 
local, 381 
Paquelin's cautery in chronic 

cases of, 384 
Schroder's operation in, 384 
tampons, 383 
tubercular, 375 
injuries of the body, 253 

treatment, 254 
inversion of, 550 
extravaginal, 550 
intrauterine, 550 
intravaginal, 550 
invagination, 551 
lateral flexion of, 546. See Flexion. 
ligaments of, 211 
malignant tumors of, 743 
carcinoma, 744 

adenocarcinoma of body, 752 

of cervix, 749 
chorioepithelioma, 744, 832 
classification of, 744 
clinical forms, 762 
endothelioma, 744, 835 
epithelioma, 748 
sarcoma, 744 
squamous cell, 746 
limit between benign and, 744 
metritis, 384. See Metritis. 
mucous membrane of, 181 
polypi of, 742 

confounded with fibroid poh^pi, 

742 
treatment of, 743 
normal position of, 468 
pathologic changes and what con- 
stitute, 469 
causes of, 470 
physiologic movements of, 467 

influence of distended bladder 
on, 468 
polypus, placental, 743 
position of, 178 
prolapsus of, 473 



96S 



INDEX. 



Uterus, puerperal tumors, 741 

hematometra, 742 

hydrometra, 742 

mucometra, 742 

physometra, 741 

pyometra, 742 
retroflexion of, 472. See Retro- 
flexion. 
retroversion, 504. See Retroversion. 
rudimentary, 228 
rupture of, 46, 254 
sarcoma. See Sarcoma. 
subinvolution of, 401, 516 
torsion of, 472, 501 
unequal development of two sides 

of, 226 
unicornis, 227 
weight of, 178 



V. 

Vagina, 172 

absent, treatment of, 233 
anterior fornix of, 173 
atresia of, 237 

of vagina and urethra, 246 
changes caused by pregnancy, 176 
closure of vesico-vaginal fistula, 269 
complete absence or rudimentary 

development of, 232 
cysts of, 622, 637 
diagnosis, 638 

differential, from cystocele or 
urethrocele, 638 
origin, 637 
symptoms, 638 
treatment, 638 
dimensions of , 1 7 2 
double, 235 
epithelioma of, 640 
fibroid tumors and polypi of, 638 
diagnosis, 639 

differential, from malig- 
nant disease, 639 
symptoms, ^639 
treatment, '639 
enucleation, 639 
lacerations of, 263 
lymphatics of, 177, 348 
malignant neoplasms, 639 
etiology of, 640 
symptoms, 640 
treatment, 641 
microscopic section of wall of, 177 
mucous membrane of, 175, 176 

secretion of, 176 
nerves, 178, 348 
papillomata of, 639 
posterior fornix of, 173 
prolapsus, or inversion of, 474 
rudimentary, 232 
rugae of , 164, 175, 176, 178 
tumors of, 637 



Vagina, unilateral, 235 

wall of, 172, 176 
Vaginal enterocele, 485 
hysterectomy, 716, 790 
irrigation, 140 
orifice, 159 

section, 458. See Section, vaginal. 
sphincter, 167, 176 
wall, excision of anterior, for cysto- 
cele, 495 
Vaginismus, 18, 19, 149, 153, 345 
cause of pain in, 19 
causes of, 345 
prognosis of, 346 
superior, 346 
symptoms, 345 
treatment, 346 
Vaginitis, colpitis, or elytritis, 348 
auto-infection, 348 
bacterial forms of secretion, 348 
diagnosis, 352 
etiology, 351 
pathology, 350 
of simple, 351 
of specific, 351 
prognosis, 353 
symptoms, 351 
synonyms of, 348 
treatment, 353 
varieties, 350 
diphtheric, 350 
dysenteric, 350 
emphysematous, 350 
exfoliative, 350 
phlegmonous, 350 
senile, 351 
simple, 350 
specific, 350 
Valve of Houston, 196 
Varicocele, parovarian, phleboliths, 858 
Vascular supply of pelvic organs, 201 
Vaselin, 77, 822 
Veins, internal, iliac, 207 
left ovarian, 207 
ovarian, 207 

pampiniform plexus, 207 
plexus of hemorrhoidal, 205 
right ovarian, 206 
superficial abdominal enlarged by 

pressure, 97 
uterine, 206 
vaginal, 207 
varicose, 628 
vesical plexus, 207 
Venereal warts or sores, 27, 332 
Ventral hernia, 98, 723, 888 
Ventrofixation of uterus, 541, 549, 566 
advantages and disadvantages of, 

543 
Ventrosuspension of uterus, 541, 549 
Version, lateral, 506 
Vertigo, obstinate, 719 
Vesical douches, 144 



INDEX. 



969 



Vesical reflexes, i8 

tenesmus, 670 
Vesico-abdominal pouch, 200 
Vesico-urethral fissure, 357 
Vesico-uterine culdesac, 199, 200 

fistula, 264, 280 
Vesico-utero-vaginal fistula, 282 
Vesico-vaginal fistula, 268 
Vestibule, 162 
bulb of, 167 
Viburnum prunifolitim, 141 
Violence, external, to genital organs, 

250 
Virgins, examination of, 30 
Viscera, inflammation of pelvic, 152 
Visceral injuries during operations, 

737. 918 
Vitelline membrane, 189 
Volvulus, 137, 921 
Vomiting, 133, 451, 695, 771, 883 
following operation, 133 
in cancer, 771 
obstinate, 133 
rectal feeding in, 134 
remedies for, 133 
rupture of cyst by, 885 
stomach tube for, 134 
Vulva, 159 

absence of, 241 

changed relations of structures of, 

466 
edema of, 338, 628 
eruptive diseases of, 334 
causes of, 334 
eczema of, 334 
erysipelas of, 334 
herpes of, 334 
gangrene of, 338 
infantile, 241 
kraurosis, 343 
neuroma, 630 

treatment of, 630 
pruritus, 341 

syphilitic hypertrophy, 338 
tumors, 622 

benign, classification of, 621 
cysts, 629 
blood, 629 
gas, 623 
liquid, 624 

hydrocele, 624 

differential diagnosis from 
hernia, 624 
of glands of Bartholin, 629 
of hymen, 629 
of urethra, 629 
sebaceous, 629 
serous, 629 
treatment of, 630 
elephantiasis, 628 
diagnosis of, 629 
forms of, 629 
symptoms of, 629 

62 



Vulva, tumors, enchondroma, 633 
erectile or vascular, 625 
diagnosis of, 627 
etiology, 626 
symptoms, 626 
treatment, 627 
urethral caruncle, 626 
fibroma and myxoma, 633 
lipoma, 633 
malignant, 621, 633 
adenocarcinoma, 633 
epithelioma, 633 
sarcoma, 633 
solid, 621, 622, 629 
neuroma, 630 
simple vegetations, 630 
condylomata, 630 
papillomata, 630 
treatment of, 630 
varicose veins of, 628 
Vulvar atresia, 237 
Vulvitis, 331 
catarrhal, 336 
causes of, 331 
chancroidal, 332 
diagnosis of, 335 
diphtheric, 335 
eruptive, 331, 334 
follicular, 332 
gonorrheal, 328, 332, 334 
herpetic, 334 
phlegmonous, 331, 335 
simple or catarrhal, 331, 336 
I pruritus a symptom, 332 

S3^philitic, ss3 
treatment of, 336 
venereal, 331, 332 
j causes of, 332 

' Vulvo- vaginal glands, 167 
inflammation of, 339 
Vulvo-vaginitis in young girls, 347, 348 
dangers of, 347 
treatment, 347 ^ 



W. 

Water, alkaline, 353, 406 

Buft'alo lithia, 369 

Carlsbad, 369, 407 

Friedrichshall, 141, 407 

Hunyadi Janos, 141, 407 

Londonderry lithia, 369 

mineral, 407, 697 

Saratoga, 368 

Seawright, 369 

Seltzer, 369 

sterilized, 119 

Vichy, 368 
Whisky, 134, 451 
White line of Farre, 187 
Wolffian body, 157, 191, 875 

duct, 157 



970 



INDEX. 



Wound, closure of, 129, 914 
dressing, 131 
infection, 136 
methods of suturing, 129 
post-operative treatment of, 131, 791 



X-rays, 154 



Z. 

Zinc alum sticks, 384 

chlorid, 146, 399, 785, 792, 823 
crayons, 146 
solution, 340 
sticks, 824 
sulphate, 146, 382, 383, 572 

crayons, 146 
valerianate, 141 
Zingiber, syrup, 133 
Zona pellucida, 189 



APR 23 1907 



